1659603322 NPI number — PYRAMID WALDEN, LLC

Table of content: (NPI 1659603322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659603322 NPI number — PYRAMID WALDEN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PYRAMID WALDEN, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659603322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30007 BUSINESS CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE HALL
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20622-3101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-997-1300
Provider Business Mailing Address Fax Number:
301-997-1321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44867 ST. ANDREWS CHURCH ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALIFORNIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-997-1300
Provider Business Practice Location Address Fax Number:
301-863-3368
Provider Enumeration Date:
02/05/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HENDRICKS
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
814-940-0407

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7800355-01 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 745188101 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".