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General NPI Number Information
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NPI Number | 1154868727
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Entity Type | Organization
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Legal Business Name | LICE CLINICS OF MARYLAND, LLC
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Dates
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Enumeration Date | 01/20/2017
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Last Update Date | 01/26/2017
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Provider Practice Location Address
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Address Line | 604 PROVIDENCE ROAD
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City | TOWSON
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State | MD
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Zip | 21286
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Country | US
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Telephone | 410-934-5423
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Fax |
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Provider Business Mailing Address
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Address Line | 604 PROVIDENCE ROAD
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City | TOWSON
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State | MD
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Zip | 21286
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Country | US
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Telephone | 410-934-5423
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MR. RALPH JAY UPDIKE
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Credential |
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Telephone | 410-934-5423
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 03003633
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License Number State | MD
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