Provider Demographics
NPI:1831359496
Name:KHULON1
Entity type:Organization
Organization Name:KHULON1
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:IBEKWE
Authorized Official - Last Name:ONWUDIWE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:301-277-7776
Mailing Address - Street 1:6103 BALTIMORE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1966
Mailing Address - Country:US
Mailing Address - Phone:301-277-7776
Mailing Address - Fax:301-277-7782
Practice Address - Street 1:6103 BALTIMORE AVE STE 203
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1966
Practice Address - Country:US
Practice Address - Phone:301-277-7776
Practice Address - Fax:301-277-7782
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KHULON1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-16
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWMATC 971343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD027801700Medicaid
DC036172400Medicaid