1578095618 NPI number — KEYS DEVELOPMENT TA LLC

Table of content: (NPI 1578095618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578095618 NPI number — KEYS DEVELOPMENT TA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYS DEVELOPMENT TA 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:
1578095618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7501 LIBERTY ROAD
Provider Second Line Business Mailing Address:
SUITES A, B, F/G & L
Provider Business Mailing Address City Name:
GWYNN OAK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21207-3870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-429-2536
Provider Business Mailing Address Fax Number:
443-429-2168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7501 LIBERTY ROAD
Provider Second Line Business Practice Location Address:
SUITES A, B, F/G & L
Provider Business Practice Location Address City Name:
GWYNN OAK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21207-3870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-429-2536
Provider Business Practice Location Address Fax Number:
443-429-2168
Provider Enumeration Date:
03/29/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
ERIKA
Authorized Official Middle Name:
TRACEY
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
443-429-2536

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  MH-1995 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4235077000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4233169400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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