Provider Demographics
NPI:1255793485
Name:TSP AT HAVEN ON THE LAKE
Entity type:Organization
Organization Name:TSP AT HAVEN ON THE LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TORI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PAIDE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:202-352-5289
Mailing Address - Street 1:5570 STERRETT PL
Mailing Address - Street 2:#202
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2641
Mailing Address - Country:US
Mailing Address - Phone:202-352-5289
Mailing Address - Fax:
Practice Address - Street 1:10275 LITTLE PATUXENT PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3412
Practice Address - Country:US
Practice Address - Phone:202-352-5289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-26
Last Update Date:2016-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01486171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty