Provider Demographics
NPI:1548913650
Name:JAYATILAKE, CHAMINDA INDIKA
Entity type:Individual
Prefix:
First Name:CHAMINDA
Middle Name:INDIKA
Last Name:JAYATILAKE
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 1:1822 ARCOLA AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-2831
Mailing Address - Country:US
Mailing Address - Phone:301-215-0163
Mailing Address - Fax:
Practice Address - Street 1:1822 ARCOLA AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-2831
Practice Address - Country:US
Practice Address - Phone:301-215-0163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15AL636310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility