MEDICARE: 4 WALLS HEALTH SERVICES 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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)

General Provider Information

NPI Number	:	1407007289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	4 WALLS HEALTH SERVICES INC.

Provider Business Mailing Address
First Line	:	6609 REISTERSTOWN RD
Second Line	:	SUITE 104
City	:	BALTIMORE
State	:	MD
Zip	:	21215-2315
Country	:	US
Telephone Number	:	443-762-6949
Fax Number	:

Provider Business Practice Location Address
First Line	:	6609 REISTERSTOWN RD
Second Line	:	SUITE 104
City	:	BALTIMORE
State	:	MD
Zip	:	21215-2315
Country	:	US
Telephone Number	:	443-762-6949
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MRS. PAMELA ANDREA GIBSON-JONES
Credential	:	CAC-AD
Telephone Number	:	443-762-6949

Provider Enumeration Date	:	10/09/2008
Last Update Date	:	10/09/2008

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