Healthcare Provider Details

I. General information

NPI: 1962168872
Provider Name (Legal Business Name): MR. ODOEMENAM BENNETH UZOMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 RACE RD STE 101
ROSEDALE MD
21237-2362
US

IV. Provider business mailing address

1232 RACE RD STE 101
ROSEDALE MD
21237-2362
US

V. Phone/Fax

Practice location:
  • Phone: 410-448-0500
  • Fax: 443-836-4343
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberDD0405
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberDD0405
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: