Healthcare Provider Details

I. General information

NPI: 1700775392
Provider Name (Legal Business Name): FA MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 BROOKS LN
BALTIMORE MD
21217-4512
US

IV. Provider business mailing address

3406 BANCROFT RD
BALTIMORE MD
21215-3105
US

V. Phone/Fax

Practice location:
  • Phone: 888-888-8888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DESIREE MOUNTAIN
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 443-204-5800