MEDICARE: MI CASA ES SU CASA INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1245615418
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MI CASA ES SU CASA INC

Provider Business Mailing Address
First Line	:	3921 OLD YORK RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-1910
Country	:	US
Telephone Number	:	443-219-7855
Fax Number	:

Provider Business Practice Location Address
First Line	:	3921 OLD YORK RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-1910
Country	:	US
Telephone Number	:	443-219-7855
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING/BILLING CONSULTANT
Name	:	MS. TERRI FIELDS
Credential	:	CPAT
Telephone Number	:	443-559-0405

Provider Enumeration Date	:	07/29/2015
Last Update Date	:	12/15/2015

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