Healthcare Provider Details

I. General information

NPI: 1912681883
Provider Name (Legal Business Name): VITALITY 360 OF BALTIMORE AT PROVIDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 PENNSYLVANIA AVE
BALTIMORE MD
21217-3135
US

IV. Provider business mailing address

4001 SEVEN MILE LN
PIKESVILLE MD
21208-6114
US

V. Phone/Fax

Practice location:
  • Phone: 443-606-6424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHIMERE BECOTE
Title or Position: FOUNDER
Credential:
Phone: 443-606-6424