Provider Demographics
NPI:1356896708
Name:WINGS OF LIFE MOBILE LLC
Entity type:Organization
Organization Name:WINGS OF LIFE MOBILE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATIONALLY CERTIFIED PHLEBOTOMIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZANDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:CEPHAS
Authorized Official - Suffix:
Authorized Official - Credentials:ASPT,CPT
Authorized Official - Phone:410-726-6573
Mailing Address - Street 1:202 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21826-2005
Mailing Address - Country:US
Mailing Address - Phone:410-726-6573
Mailing Address - Fax:410-572-4143
Practice Address - Street 1:202 HOLLY ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:MD
Practice Address - Zip Code:21826-2005
Practice Address - Country:US
Practice Address - Phone:410-726-6573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-15
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246RP1900X, 251E00000X
MD681104140001320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty
No251E00000XAgenciesHome Health