Healthcare Provider Details

I. General information

NPI: 1609663368
Provider Name (Legal Business Name): GREY PHOENIX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2689 ORCHARD ORIOLE WAY
ODENTON MD
21113-3120
US

IV. Provider business mailing address

2689 ORCHARD ORIOLE WAY
ODENTON MD
21113-3120
US

V. Phone/Fax

Practice location:
  • Phone: 202-681-9190
  • Fax:
Mailing address:
  • Phone: 202-681-9190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: OLADIPUPO ADENUBI
Title or Position: MD/ CEO
Credential:
Phone: 202-681-9190