=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720627151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TITOMO HEALTHCARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2020
-----------------------------------------------------
Last Update Date | 06/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1708 GREENS LN
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21076-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-583-0528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1708 GREENS LN
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21076-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-583-0528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO / CRNP-PMH
-----------------------------------------------------
Name | MR. TAJUDEEN OMODEOYE
-----------------------------------------------------
Credential | CRNP-PMH
-----------------------------------------------------
Telephone | 240-583-0528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------