Provider Demographics
NPI:1437654456
Name:MARYLAND HOUSE DETOX, LLC
Entity Type:Organization
Organization Name:MARYLAND HOUSE DETOX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BORKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-487-1224
Mailing Address - Street 1:PO BOX 714784
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-4784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:817 S CAMP MEADE RD
Practice Address - Street 2:
Practice Address - City:LINTHICUM HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:21090-3032
Practice Address - Country:US
Practice Address - Phone:954-487-1224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-30
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility