Provider Demographics
NPI:1205537016
Name:MARYLAND SUCCESS ACADEMY LLC DBA MARYLAND SUCCESS LAB LLC
Entity type:Organization
Organization Name:MARYLAND SUCCESS ACADEMY LLC DBA MARYLAND SUCCESS LAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:MED, NURSE EDUCATOR
Authorized Official - Phone:443-353-9729
Mailing Address - Street 1:9854 LIBERTY RD STE E
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2058
Mailing Address - Country:US
Mailing Address - Phone:443-353-9729
Mailing Address - Fax:
Practice Address - Street 1:9854 LIBERTY RD STE E
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-2058
Practice Address - Country:US
Practice Address - Phone:443-353-9729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies