MEDICARE: RODERICK CLARK DORSEY JR.

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	3747P1801X	Personal Care Attendant		DC

General Provider Information

NPI Number	:	1770232340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RODERICK CLARK DORSEY JR.

Provider Business Mailing Address
First Line	:	1201 POTOMAC AVE SE UNIT 1
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20003-5122
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	307 K ST NW APT 506
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20001-3347
Country	:	US
Telephone Number	:	202-280-0683
Fax Number	:

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

Provider Enumeration Date	:	03/21/2022
Last Update Date	:	03/21/2022

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