1881063154 NPI number — SUPPLEMENTAL HEALTH

Table of content: (NPI 1881063154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881063154 NPI number — SUPPLEMENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPPLEMENTAL HEALTH
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:
1881063154
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9891 COLUMBIA LANE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
21046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-362-0114
Provider Business Mailing Address Fax Number:
866-566-5311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1292 LIMIT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDLEWYLDE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21239-1747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-801-5816
Provider Business Practice Location Address Fax Number:
866-566-5311
Provider Enumeration Date:
09/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PATE
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OCCUPAITONAL THERAPIST
Authorized Official Telephone Number:
410-801-5816

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  05863 , 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)





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