Provider Demographics
NPI:1366015455
Name:LIFE ENHANCEMENT SERVICES OF MD, LLC
Entity Type:Organization
Organization Name:LIFE ENHANCEMENT SERVICES OF MD, LLC
Other - Org Name:LIFE ENHANCEMENT SERVICES MARYLAND
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:202-269-2401
Mailing Address - Street 1:1818 NEW YORK AVE NE STE 115
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-1851
Mailing Address - Country:US
Mailing Address - Phone:202-269-2401
Mailing Address - Fax:
Practice Address - Street 1:6340 SECURITY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-5173
Practice Address - Country:US
Practice Address - Phone:202-269-2401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)