MEDICARE: MR. VICTOR L MUKASA CP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1588143630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VICTOR L MUKASA CP

Provider Business Mailing Address
First Line	:	18824 BENT WILLOW CIR APT 324
Second Line	:
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-7323
Country	:	US
Telephone Number	:	202-431-2602
Fax Number	:

Provider Business Practice Location Address
First Line	:	13000 HARBOR CENTER DR STE 312
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-2847
Country	:	US
Telephone Number	:	202-431-2602
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2018
Last Update Date	:	08/09/2018

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