Healthcare Provider Details

I. General information

NPI: 1639991318
Provider Name (Legal Business Name): TYRONE DEVORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 04/11/2026
Certification Date: 04/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W PENNSYLVANIA AVE STE 602A
TOWSON MD
21204-5005
US

IV. Provider business mailing address

22 W PENNSYLVANIA AVE STE 602A
TOWSON MD
21204-5005
US

V. Phone/Fax

Practice location:
  • Phone: 410-630-9063
  • Fax:
Mailing address:
  • Phone: 410-630-9063
  • Fax: 410-630-9063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberRSA-02483
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberRSA-02483
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: