Healthcare Provider Details

I. General information

NPI: 1962153387
Provider Name (Legal Business Name): PINK HEART HEALTH SERVICES & ACADEMY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 02/13/2022
Certification Date: 02/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 CAMBRIDGE RD
EDGEWATER MD
21037-1733
US

IV. Provider business mailing address

1609 CAMBRIDGE RD
EDGEWATER MD
21037-1733
US

V. Phone/Fax

Practice location:
  • Phone: 410-212-0392
  • Fax:
Mailing address:
  • Phone: 443-822-4439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. DOMINIQUE CHANTEL CULLY
Title or Position: CEO
Credential: BSN RN
Phone: 443-822-4439