=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073151262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNER GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2019
-----------------------------------------------------
Last Update Date | 12/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3055 FLORENCE RD
-----------------------------------------------------
City | WOODBINE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21797-7834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-499-7586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3055 FLORENCE RD
-----------------------------------------------------
City | WOODBINE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21797-7834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-499-7586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARTIN VENDEMIA
-----------------------------------------------------
Credential | BCH, MNLP
-----------------------------------------------------
Telephone | 410-499-7586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------