=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467823773
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK WEST HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2015
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4151 PARK HEIGHTS AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21215-6730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-884-7642
-----------------------------------------------------
Fax | 443-423-0002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4151 PARK HEIGHTS AVENUE HIDDEN GARDEN PROGRAM
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-884-7642
-----------------------------------------------------
Fax | 443-423-0002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROJECT DIRECTOR
-----------------------------------------------------
Name | MRS. CLEO LAVERNE EDMONDS
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 443-884-7642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------