Basic Information
| Provider Information | |||||||||
| NPI: | 1831417476 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CIVISTA CLINICAL SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CIVISTA WOMEN'S HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 GARRETT AVENUE | ||||||||
| Address2: | PO BOX 1070 | ||||||||
| City: | LA PLATA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206461070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016094000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11315 PEMBROOKE SQ STE 111 | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206034806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018433150 | ||||||||
| FaxNumber: | 3018432560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2010 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONTES DE OCA | ||||||||
| AuthorizedOfficialFirstName: | IVETTE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3018433150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CIVISTA MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | D0065304 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.