1861689382 NPI number — LIFEBRIDGE INVESTMENTS, INC

Table of content: MRS. CALLIE ELIZABETH ACREE O.T. (NPI 1720260029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861689382 NPI number — LIFEBRIDGE INVESTMENTS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFEBRIDGE INVESTMENTS, INC
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:
6
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:
1861689382
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/11/2008
NPI Reactivation Date:
04/23/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 FAIRMOUNT AVE
Provider Second Line Business Mailing Address:
CREDENTIALING OFFICE
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-494-1324
Provider Business Mailing Address Fax Number:
410-494-1361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 FAIRMOUNT AVE
Provider Second Line Business Practice Location Address:
STE 100A
Provider Business Practice Location Address City Name:
TOWSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21286-5466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-494-1315
Provider Business Practice Location Address Fax Number:
410-494-1361
Provider Enumeration Date:
09/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER
Authorized Official First Name:
G
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
410-296-5300

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QE0800X , with the licence number: A , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 417384800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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