Healthcare Provider Details

I. General information

NPI: 1619026432
Provider Name (Legal Business Name): JOPPA HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 PULASKI HWY # A
JOPPA MD
21085-3914
US

IV. Provider business mailing address

623 PULASKI HWY # A
JOPPA MD
21085-3914
US

V. Phone/Fax

Practice location:
  • Phone: 410-538-5809
  • Fax: 410-538-4249
Mailing address:
  • Phone: 410-538-5809
  • Fax: 410-538-4249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number11026
License Number StateMD

VIII. Authorized Official

Name: MR. BRENT GARRETT BOWMAN
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: CAC-AD
Phone: 410-259-4985