Basic Information
| Provider Information | |||||||||
| NPI: | 1811411648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY'S CENTER FOR MATERNAL & CHILD CARE, INC- ROOSEVELT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 ONTARIO RD NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200092627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024207175 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4301 13TH ST NW | ||||||||
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| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200115629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024838196 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2017 | ||||||||
| LastUpdateDate: | 08/02/2017 | ||||||||
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| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2024207162 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN, MPH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.