Provider Demographics
NPI: | 1760920292 |
---|---|
Name: | BLANK-PAGES LLC |
Entity Type: | Organization |
Organization Name: | BLANK-PAGES LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LASHAY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | JOHNSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 202-567-9199 |
Mailing Address - Street 1: | 4019 NIGHT HERON CT |
Mailing Address - Street 2: | B |
Mailing Address - City: | WALDORF |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 20603-4673 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3200 CRAIN HWY |
Practice Address - Street 2: | 203 |
Practice Address - City: | WALDORF |
Practice Address - State: | MD |
Practice Address - Zip Code: | 20603-4841 |
Practice Address - Country: | US |
Practice Address - Phone: | 202-567-9199 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-02-03 |
Last Update Date: | 2017-02-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | LC6054 | 251S00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | 251042100 | Medicaid | |
MD | 879798 | Other | BEACON |