MEDICARE: IVAN LAUTRY KINFACK

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

General Provider Information

NPI Number	:	1851867816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVAN LAUTRY KINFACK

Provider Business Mailing Address
First Line	:	3809 64TH AVE
Second Line	:
City	:	LANDOVER HILLS
State	:	MD
Zip	:	20784-1816
Country	:	US
Telephone Number	:	202-306-9773
Fax Number	:

Provider Business Practice Location Address
First Line	:	3809 64TH AVE
Second Line	:
City	:	LANDOVER HILLS
State	:	MD
Zip	:	20784-1816
Country	:	US
Telephone Number	:	202-306-9773
Fax Number	:

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

Provider Enumeration Date	:	10/17/2018
Last Update Date	:	10/17/2018

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Directions to “ IVAN LAUTRY KINFACK ” Practice Location

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