1518604990 NPI number — DIAMONDS OF THE ROUGH LLC

Table of content: LORI SKYE RYAN RN (NPI 1972993046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518604990 NPI number — DIAMONDS OF THE ROUGH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAMONDS OF THE ROUGH 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:
1518604990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6554
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21045-6554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-520-0621
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 GREENMOUNT AVE
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:
21218-4991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-554-8905
Provider Business Practice Location Address Fax Number:
410-480-0110
Provider Enumeration Date:
05/17/2022

Additional Information

Authorized Official

Authorized Official Last Name:
HAMILTON
Authorized Official First Name:
SHANNTELL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
443-554-8905

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 206933400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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