Provider Demographics
NPI:1134821531
Name:PENDLETON, ROOSEVELT III
Entity type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:PENDLETON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4506 OLD BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-1808
Mailing Address - Country:US
Mailing Address - Phone:925-303-3391
Mailing Address - Fax:
Practice Address - Street 1:2515 ALABAMA AVE SE APT 309
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3249
Practice Address - Country:US
Practice Address - Phone:202-836-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant