Healthcare Provider Details

I. General information

NPI: 1356896708
Provider Name (Legal Business Name): WINGS OF LIFE MOBILE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 HOLLY ST
FRUITLAND MD
21826-2005
US

IV. Provider business mailing address

202 HOLLY ST
FRUITLAND MD
21826-2005
US

V. Phone/Fax

Practice location:
  • Phone: 410-726-6573
  • Fax:
Mailing address:
  • Phone: 410-726-6573
  • Fax: 410-572-4143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number681104140001
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. ZANDRA E CEPHAS
Title or Position: NATIONALLY CERTIFIED PHLEBOTOMIST
Credential: ASPT,CPT
Phone: 410-726-6573