MEDICARE: ETHEL AGBOR OROCK MANGET

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	HHA13547	DC

General Provider Information

NPI Number	:	1679078000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHEL AGBOR OROCK MANGET

Provider Business Mailing Address
First Line	:	3307 DODGE PARK RD APT 202
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-2110
Country	:	US
Telephone Number	:	240-714-0952
Fax Number	:

Provider Business Practice Location Address
First Line	:	3307 DODGE PARK RD APT 202
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-2110
Country	:	US
Telephone Number	:	240-714-0952
Fax Number	:

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

Provider Enumeration Date	:	03/27/2018
Last Update Date	:	04/11/2018

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