Healthcare Provider Details

I. General information

NPI: 1043652811
Provider Name (Legal Business Name): RECONNECT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9825 GOOD LUCK RD APT 7
SEABROOK MD
20706-3364
US

IV. Provider business mailing address

9825 GOOD LUCK RD APT 7
SEABROOK MD
20706-3364
US

V. Phone/Fax

Practice location:
  • Phone: 240-291-8313
  • Fax:
Mailing address:
  • Phone: 240-291-8313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberLC4175
License Number StateMD

VIII. Authorized Official

Name: OLUFUNKE OYERONKE ADETUNJI
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 240-291-8313