MEDICARE: EAST OF THE RIVER CLERGY POLICE COMMUNITY PARTNERSHIP, INC.

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	251S00000X	Community/Behavioral Health Agency	52227	DC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52227701012073	OTHER	DC	BUSINESS LICENSE

General Provider Information

NPI Number	:	1952661852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST OF THE RIVER CLERGY POLICE COMMUNITY PARTNERSHIP, INC.

Provider Business Mailing Address
First Line	:	4115 1ST ST SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20032-2815
Country	:	US
Telephone Number	:	202-373-5767
Fax Number	:	202-373-5769

Provider Business Practice Location Address
First Line	:	4115 1ST ST SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20032-2815
Country	:	US
Telephone Number	:	202-373-5767
Fax Number	:	202-373-5769

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. DONALD ISAAC
Credential	:
Telephone Number	:	202-373-5667

Provider Enumeration Date	:	05/24/2012
Last Update Date	:	05/24/2012

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