Healthcare Provider Details

I. General information

NPI: 1669988515
Provider Name (Legal Business Name): EASTERN SHORE BROKERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12641 BLUEBERRY RD
WHALEYVILLE MD
21872-2013
US

IV. Provider business mailing address

PO BOX 123
WHALEYVILLE MD
21872-0123
US

V. Phone/Fax

Practice location:
  • Phone: 410-726-2967
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA TRUITT
Title or Position: OWNER/CASE MANAGEMENT
Credential:
Phone: 443-614-8873