Provider Demographics
NPI:1467179507
Name:ENRICHING LIVES SUPPORT SERVICES INC
Entity Type:Organization
Organization Name:ENRICHING LIVES SUPPORT SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAQUISA
Authorized Official - Middle Name:DESEAN
Authorized Official - Last Name:NASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-332-5777
Mailing Address - Street 1:911 W 36TH ST STE 2&7
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2445
Mailing Address - Country:US
Mailing Address - Phone:443-332-5777
Mailing Address - Fax:
Practice Address - Street 1:911 W 36TH ST STE 2&7
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2445
Practice Address - Country:US
Practice Address - Phone:443-332-5777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health