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General NPI Number Information
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NPI Number | 1356896708
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Entity Type | Organization
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Legal Business Name | WINGS OF LIFE MOBILE LLC
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Dates
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Enumeration Date | 08/15/2016
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Last Update Date | 09/13/2019
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Provider Practice Location Address
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Address Line | 202 HOLLY ST
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City | FRUITLAND
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State | MD
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Zip | 21826-2005
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Country | US
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Telephone | 410-726-6573
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Fax |
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Provider Business Mailing Address
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Address Line | 202 HOLLY ST
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City | FRUITLAND
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State | MD
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Zip | 21826-2005
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Country | US
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Telephone | 410-726-6573
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Fax | 410-572-4143
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Authorized Official
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Title or Position | NATIONALLY CERTIFIED PHLEBOTOMIST
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Name | MRS. ZANDRA E CEPHAS
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Credential | ASPT,CPT
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Telephone | 410-726-6573
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246RP1900X
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Taxonomy Name | Phlebotomy Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 681104140001
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License Number State | MD
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