Basic Information
| Provider Information | |||||||||
| NPI: | 1750633855 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY'S CENTER FOR MATERNAL AND CHILD CARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARY'S CENTER FOR MATERNAL AND CHILD CARE, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 ONTARIO RD NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200092627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024838196 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8709 FLOWER AVE | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209014035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024838196 | ||||||||
| FaxNumber: | 2404853190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2012 | ||||||||
| LastUpdateDate: | 09/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | NAZARIO | ||||||||
| AuthorizedOfficialFirstName: | MARANGELY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2024207175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 037536500 | 05 | DC | MEDICAID | 039315100 | 05 | MD | MEDICAID | 411949500 | 05 | MD | MEDICAID | 037564900 | 05 | DC | MEDICAID |