1184057481 NPI number — FREEDOM HEALTHCARE, LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184057481 NPI number — FREEDOM HEALTHCARE, LLC

Employer Identification Number (EIN):

Provider Organization Name:

FREEDOM HEALTHCARE, 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 Other Organization Name:

COMMUNITY WELLNESS CENTER

Provider Other Organization Name Type Code:

3

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:

1184057481

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

01/28/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3310 EASTERN AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

BALTIMORE

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21224-4108

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

437-085-0564

Provider Business Mailing Address Fax Number:

443-449-7897

Provider First Line Business Practice Location Address:

1119 E MONUMENT ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

BALTIMORE

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

21202

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

443-705-5056

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

08/10/2013

Authorized Official Last Name:

HOLMES

Authorized Official First Name:

VERNON

Authorized Official Middle Name:

Authorized Official Title or Position:

CEO

Authorized Official Telephone Number:

202-320-0501

• Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261Q00000X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .