Provider Demographics
NPI:1609184951
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:Doing Business As
Authorized Official - Title/Position:MEMBER/CFO
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:YEATER
Authorized Official - Suffix:
Authorized Official - Credentials:
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:
Practice Address - Street 1:932 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-3324
Practice Address - Country:US
Practice Address - Phone:410-810-1370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD01110310001Medicaid