Healthcare Provider Details

I. General information

NPI: 1679863344
Provider Name (Legal Business Name): NATIVE AMERICAN LIFELINES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 CLAY ST
BALTIMORE MD
21201-3501
US

IV. Provider business mailing address

106 CLAY ST
BALTIMORE MD
21201-3501
US

V. Phone/Fax

Practice location:
  • Phone: 410-837-2258
  • Fax: 410-837-2692
Mailing address:
  • Phone: 410-837-2258
  • Fax: 410-837-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number9848
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number904244
License Number StateMD

VIII. Authorized Official

Name: MRS. SUSAN ROTH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 410-837-2258