Provider Demographics
NPI:1174998009
Name:ESSENTIALS SOULON
Entity type:Organization
Organization Name:ESSENTIALS SOULON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEJUAN
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-802-3098
Mailing Address - Street 1:6600 HORSESHOE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2537
Mailing Address - Country:US
Mailing Address - Phone:202-802-3098
Mailing Address - Fax:301-836-1772
Practice Address - Street 1:2736 KEATING ST
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-1512
Practice Address - Country:US
Practice Address - Phone:202-802-3098
Practice Address - Fax:301-836-1772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1013275445Other1174998009