Provider Demographics
NPI:1174949358
Name:THE VILLAGE PEDIATRIC & WELLNESS CENTER
Entity type:Organization
Organization Name:THE VILLAGE PEDIATRIC & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:DEL CARMEN
Authorized Official - Last Name:POURRAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-637-3005
Mailing Address - Street 1:50 W EDMONSTON DR STE 502
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-1222
Mailing Address - Country:US
Mailing Address - Phone:301-637-3005
Mailing Address - Fax:866-890-7221
Practice Address - Street 1:50 W EDMONSTON DR STE 502
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-1222
Practice Address - Country:US
Practice Address - Phone:301-637-3005
Practice Address - Fax:866-890-7221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062518261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10234246Medicaid