NPIMap

Organization Active NPI

Civista Clinical Services LLC

Doing business as Civista Women's Health Center

  • Multi-Specialty Clinic/Center
  • Waldorf, MD
National Provider Identifier
1831417476
Registry record updated Dec 17, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
License
D0065304 Issued in MD
Legal business name
CIVISTA CLINICAL SERVICES LLC
Doing business as
Civista Women's Health Center
Practice address
11315 Pembrooke SQ Ste 111
Waldorf, MD 20603-4806
Phone
(301) 843-3150
Fax
(301) 843-2560
NPI assigned
May 6, 2010
Organization subpart
Yes
Parent organization
CIVISTA MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 17, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Ivette M Montes de Oca
Title
Practice Manager
Phone
(301) 843-3150

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X D0065304 MD Primary

Addresses

Primary practice location

11315 Pembrooke SQ Ste 111
Waldorf, MD 20603-4806

Mailing address

5 Garrett Avenue
PO Box 1070
La Plata, MD 20646-1070
Phone (301) 609-4000

Other names 1

  • Civista Women's Health Center Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Civista Clinical SRVC LLC4 organizations share this tax ID, including this one
Part of
Civista Medical Center

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1309 Jamestown Rd
Ste 101
Williamsburg, VA 23185
Phone (757) 220-0645

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1273104000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1576540800000",
    "number": "1831417476",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5 GARRETT AVENUE",
            "address_2": "PO BOX 1070",
            "city": "LA PLATA",
            "state": "MD",
            "postal_code": "206461070",
            "telephone_number": "301-609-4000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11315 PEMBROOKE SQ STE 111",
            "city": "WALDORF",
            "state": "MD",
            "postal_code": "206034806",
            "telephone_number": "301-843-3150",
            "fax_number": "301-843-2560"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CIVISTA CLINICAL SERVICES LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CIVISTA MEDICAL CENTER",
        "enumeration_date": "2010-05-06",
        "last_updated": "2019-12-17",
        "certification_date": "2019-12-17",
        "status": "A",
        "authorized_official_last_name": "MONTES DE OCA",
        "authorized_official_first_name": "IVETTE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "301-843-3150",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "MD",
            "license": "D0065304",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Civista Women's Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Civista Women's Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waldorf, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 17, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.