1720719164 NPI number — OPEN MINDED HEALTH CARE, LLC

Table of content: (NPI 1720719164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720719164 NPI number — OPEN MINDED HEALTH CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN MINDED HEALTH CARE, 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:
1720719164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10482 BALTIMORE AVE UNIT 324
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELTSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20705-2321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-557-8719
Provider Business Mailing Address Fax Number:
667-200-4711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 HOLIDAY DR
Provider Second Line Business Practice Location Address:
STE C-1
Provider Business Practice Location Address City Name:
SOLOMONS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20688
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
667-910-8540
Provider Business Practice Location Address Fax Number:
667-200-4711
Provider Enumeration Date:
06/17/2022

Additional Information

Authorized Official

Authorized Official Last Name:
OKORO
Authorized Official First Name:
OSAZE
Authorized Official Middle Name:
ERNEST
Authorized Official Title or Position:
MEDICAL DIRECTOR / OWNER
Authorized Official Telephone Number:
443-557-8719

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 208525900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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