Provider Demographics
NPI:1831417476
Name:CIVISTA CLINICAL SERVICES LLC
Entity type:Organization
Organization Name:CIVISTA CLINICAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:IVETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MONTES DE OCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-843-3150
Mailing Address - Street 1:5 GARRETT AVENUE
Mailing Address - Street 2:PO BOX 1070
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-1070
Mailing Address - Country:US
Mailing Address - Phone:301-609-4000
Mailing Address - Fax:
Practice Address - Street 1:11315 PEMBROOKE SQ STE 111
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4806
Practice Address - Country:US
Practice Address - Phone:301-843-3150
Practice Address - Fax:301-843-2560
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIVISTA MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-06
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065304261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty