1790156891 NPI number — ANTORIAN CONSULTING SERVICES

Table of content: (NPI 1790156891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790156891 NPI number — ANTORIAN CONSULTING SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTORIAN CONSULTING SERVICES
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:
1790156891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3545 ELLICOTT MILLS DR PMB 204
Provider Second Line Business Mailing Address:
PMB 204
Provider Business Mailing Address City Name:
ELLICOTT CITY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21043-4548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-246-2830
Provider Business Mailing Address Fax Number:
410-246-2831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7004 SECURITY BLVD # 300-A27
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:
21244-2557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-246-2830
Provider Business Practice Location Address Fax Number:
410-246-2831
Provider Enumeration Date:
10/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE-HEBRON
Authorized Official First Name:
AN'NITA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-246-2830

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R154023 , 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: 429909400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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