Healthcare Provider Details

I. General information

NPI: 1629699293
Provider Name (Legal Business Name): SOVEREIGNTY HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 OLD COURT RD
RANDALLSTOWN MD
21133-5243
US

IV. Provider business mailing address

152 SPECTATOR LN
OWINGS MILLS MD
21117-4444
US

V. Phone/Fax

Practice location:
  • Phone: 410-940-1983
  • Fax:
Mailing address:
  • Phone: 410-940-1983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KEHINDE TIJANI
Title or Position: OTR/L
Credential:
Phone: 410-940-1983