=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497102867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIKESVILLE HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2016
-----------------------------------------------------
Last Update Date | 08/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1209 GREENWOOD RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-415-6384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2833 SMITHE AVE SUITE # 148
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-415-6384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM SPONSOR
-----------------------------------------------------
Name | AMIEL CHICHEPORTICHE
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 410-415-6384
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 906136
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2800X
-----------------------------------------------------
Taxonomy Name | Methadone Clinic
-----------------------------------------------------
License Number | 906136
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------