Healthcare Provider Details

I. General information

NPI: 1114446531
Provider Name (Legal Business Name): TRUE VINE ADULT MEDICAL DAY CARE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5629 HARFORD RD
BALTIMORE MD
21214-2272
US

IV. Provider business mailing address

5629 HARFORD RD
BALTIMORE MD
21214-2272
US

V. Phone/Fax

Practice location:
  • Phone: 410-444-0204
  • Fax: 410-444-0124
Mailing address:
  • Phone: 410-444-0204
  • Fax: 410-444-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCUS MOTTON
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 410-444-0204