Healthcare Provider Details

I. General information

NPI: 1083102511
Provider Name (Legal Business Name): RIVERSIDE TREATMENT SERVICES LANSDOWNE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 LANSDOWNE RD
LANSDOWNE MD
21227-1707
US

IV. Provider business mailing address

8359 PULASKI HWY
ROSEDALE MD
21237-2948
US

V. Phone/Fax

Practice location:
  • Phone: 443-691-5358
  • Fax:
Mailing address:
  • Phone: 443-730-6104
  • Fax: 443-730-6109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL H OLIVER
Title or Position: PRINCIPAL
Credential:
Phone: 443-739-6104