Organization
TYPE 1 INDIVIDUAL PROVIDER
Active
Other names
Type 1 Individual Provider
Organization subpart
No
Provider details
NPI number
Authorized official
MS. BRENA GIBSON P.H.D (HUMAN RESOURCES DIRECTOR)
(301) 439-7191
Entity
Organization
Contact information
Practice address
1620 ELTON RD, SILVER SPRING, MD 20903-1740
(301) 439-7191
Mailing address
1620 ELTON RD, SILVER SPRING, MD 20903-1740
(301) 439-7191
Taxonomy
Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
Primary
LC2381
MD
Other
Enumeration date
04/02/2009
Last updated
04/08/2009
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