Healthcare Provider Details

I. General information

NPI: 1841715976
Provider Name (Legal Business Name): VASTLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6106 EDMONDSON AVE STE 102
CATONSVILLE MD
21228-1885
US

IV. Provider business mailing address

6106 EDMONDSON AVE STE 102
CATONSVILLE MD
21228-1885
US

V. Phone/Fax

Practice location:
  • Phone: 301-978-6321
  • Fax: 301-965-8625
Mailing address:
  • Phone: 301-978-6321
  • Fax: 301-965-8625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberR4108
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberR4101
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberR4108
License Number StateMD

VIII. Authorized Official

Name: WELLINGTON OGUDE
Title or Position: ADMINISTRATOR
Credential:
Phone: 202-460-0403