Healthcare Provider Details

I. General information

NPI: 1104640663
Provider Name (Legal Business Name): CHANCE FOR LIFE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6490 LANDOVER RD STE F6
CHEVERLY MD
20785-1443
US

IV. Provider business mailing address

4623 MORNING GLORY TRL
BOWIE MD
20720-4264
US

V. Phone/Fax

Practice location:
  • Phone: 202-487-9587
  • Fax: 240-770-7529
Mailing address:
  • Phone: 202-487-9587
  • Fax: 240-770-7529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OLUWAKEMI FAGBUYI
Title or Position: OWNER OF ENTITY
Credential: MSN, APRN, PMHNP-BC
Phone: 202-487-9587