=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679863344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIVE AMERICAN LIFELINES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2011
-----------------------------------------------------
Last Update Date | 08/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 CLAY ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-837-2258
-----------------------------------------------------
Fax | 410-837-2692
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 CLAY ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-837-2258
-----------------------------------------------------
Fax | 410-837-2692
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. SUSAN ROTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-837-2258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 904244
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 9848
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------