Provider Demographics
NPI:1639475809
Name:LOCH RAVEN CLC
Entity Type:Organization
Organization Name:LOCH RAVEN CLC
Other - Org Name:VETERANS AFFAIRS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:RECREATION RECREATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONDRA
Authorized Official - Middle Name:HARDY
Authorized Official - Last Name:OTUKOYA
Authorized Official - Suffix:
Authorized Official - Credentials:CTRS
Authorized Official - Phone:410-605-7000
Mailing Address - Street 1:3900 LOCH RAVEN BLVD.
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218
Mailing Address - Country:US
Mailing Address - Phone:410-605-7000
Mailing Address - Fax:410-605-7589
Practice Address - Street 1:3900 LOCH RAVEN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2108
Practice Address - Country:US
Practice Address - Phone:410-605-7000
Practice Address - Fax:410-605-7589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16012273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD225800000XMedicare UPIN