Healthcare Provider Details

I. General information

NPI: 1043043201
Provider Name (Legal Business Name): BROAD PLACE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 09/01/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3608 MILFORD MILL RD
WINDSOR MILL MD
21244-3328
US

IV. Provider business mailing address

3608 MILFORD MILL RD
WINDSOR MILL MD
21244-3328
US

V. Phone/Fax

Practice location:
  • Phone: 240-360-3693
  • Fax: 443-405-7237
Mailing address:
  • Phone: 240-360-3693
  • Fax: 443-405-7237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: DR. ABIMBOLA RUNSEWE
Title or Position: CEO
Credential: DNP
Phone: 240-360-3693