Provider Demographics
NPI:1154724094
Name:ESSENTIALS SOUL-ON LLC
Entity type:Organization
Organization Name:ESSENTIALS SOUL-ON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEJUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-802-3098
Mailing Address - Street 1:6600 HORSESHOE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2537
Mailing Address - Country:US
Mailing Address - Phone:202-802-3098
Mailing Address - Fax:
Practice Address - Street 1:7902 OLD BRANCH AVE
Practice Address - Street 2:105
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-1646
Practice Address - Country:US
Practice Address - Phone:202-802-3098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD425560335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier