=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891573424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REHOBOTH SUPPORT SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2023
-----------------------------------------------------
Last Update Date | 09/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7007 SEQUOIA PL
-----------------------------------------------------
City | BELTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20705-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-740-9056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7007 SEQUOIA PL
-----------------------------------------------------
City | BELTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20705-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-740-9056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ATINUKE FADIPE
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 240-278-1871
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------