Healthcare Provider Details

I. General information

NPI: 1508245564
Provider Name (Legal Business Name): WATERMARK HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2015
Last Update Date: 05/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11511 RIDGEDALE DR
WHITE MARSH MD
21162-1146
US

IV. Provider business mailing address

11511 RIDGEDALE DR
WHITE MARSH MD
21162-1146
US

V. Phone/Fax

Practice location:
  • Phone: 410-230-1840
  • Fax:
Mailing address:
  • Phone: 410-230-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberR3747
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. BABAJIDE JOHNSON ADEDIPE
Title or Position: ADMINISTRATOR
Credential: LPN
Phone: 410-262-7321