Provider Demographics
NPI:1750021614
Name:FRESH FRESH HEALTH CARE AGENCY LLC,
Entity Type:Organization
Organization Name:FRESH FRESH HEALTH CARE AGENCY LLC,
Other - Org Name:FRESH FRESH HEALTHCARE CANNABIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:K
Authorized Official - Last Name:RODNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD DR PHYSIOLOGY
Authorized Official - Phone:202-823-9346
Mailing Address - Street 1:7604 VICAR PL
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2966
Mailing Address - Country:US
Mailing Address - Phone:202-823-9346
Mailing Address - Fax:
Practice Address - Street 1:7604 VICAR PL
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-2966
Practice Address - Country:US
Practice Address - Phone:202-823-9346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-30
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No282J00000XHospitalsReligious Nonmedical Health Care InstitutionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDW20782660OtherOTHER LOCATIONS LICENSED