Healthcare Provider Details

I. General information

NPI: 1780505693
Provider Name (Legal Business Name): INNERLIGHT RESIDENTIAL CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 CANVASBACK CT
UPPER MARLBORO MD
20774-7001
US

IV. Provider business mailing address

1110 CANVASBACK CT
UPPER MARLBORO MD
20774-7001
US

V. Phone/Fax

Practice location:
  • Phone: 240-893-0842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TOLULOPE DAVID TELLI
Title or Position: CEO
Credential:
Phone: 240-893-0842