Provider Demographics
NPI:1417690439
Name:GAMBRILLS SISTERS HEALTH CARE
Entity type:Organization
Organization Name:GAMBRILLS SISTERS HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FATU
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROMA
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:240-437-2705
Mailing Address - Street 1:106 CALUMET CT
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1060
Mailing Address - Country:US
Mailing Address - Phone:240-437-2705
Mailing Address - Fax:
Practice Address - Street 1:106 CALUMET CT
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1060
Practice Address - Country:US
Practice Address - Phone:240-437-2705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR187334OtherLICENSE