Provider Demographics
NPI:1124028535
Name:MARYLAND REAL LIFE DESIGNS, LLC
Entity Type:Organization
Organization Name:MARYLAND REAL LIFE DESIGNS, LLC
Other - Org Name:REAL LIFE PROSTHETICS
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER/ PRESIDENT
Authorized Official - Prefix:PROF
Authorized Official - First Name:JONAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:SEEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:410-569-0606
Mailing Address - Street 1:3435 BOX HILL CORPORATE CENTER DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-1204
Mailing Address - Country:US
Mailing Address - Phone:410-569-0606
Mailing Address - Fax:410-569-7477
Practice Address - Street 1:3435 BOX HILL CORPORATE CENTER DR
Practice Address - Street 2:SUITE D
Practice Address - City:ABINGDON
Practice Address - State:MD
Practice Address - Zip Code:21009-1204
Practice Address - Country:US
Practice Address - Phone:410-569-0606
Practice Address - Fax:410-569-7477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12027054335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD011103100Medicaid
MD4090110001Medicare NSC