Provider Demographics
NPI:1174945653
Name:KEMDA KEMTSOP, GILBERT BOLI
Entity type:Individual
Prefix:
First Name:GILBERT BOLI
Middle Name:
Last Name:KEMDA KEMTSOP
Suffix:
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 1:4608 6TH PL NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2205
Mailing Address - Country:US
Mailing Address - Phone:202-412-7103
Mailing Address - Fax:
Practice Address - Street 1:4608 6TH PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2205
Practice Address - Country:US
Practice Address - Phone:202-412-7103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA8067374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide