MEDICARE: ANEW INSPIRED CHANGE ORGANIZATION

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	3104A0625X	Assisted Living Facility (Mental Illness)	MD
2	3104A0630X	Assisted Living Facility (Behavioral Disturbances)	MD
3	310400000X	Assisted Living Facility	MD

General Provider Information

NPI Number	:	1790273522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANEW INSPIRED CHANGE ORGANIZATION

Provider Business Mailing Address
First Line	:	1400 MERCANTILE LN STE 246
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-5353
Country	:	US
Telephone Number	:	301-971-2639
Fax Number	:	301-386-5262

Provider Business Practice Location Address
First Line	:	1400 MERCANTILE LN STE 246
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-5353
Country	:	US
Telephone Number	:	301-971-2639
Fax Number	:	301-386-5262

Authorized Official
Title or Position	:	DIRECTOR
Name	:	PORSHIA EVERETT
Credential	:
Telephone Number	:	301-971-2639

Provider Enumeration Date	:	04/26/2018
Last Update Date	:	06/16/2018

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