Provider Demographics
NPI:1669988515
Name:EASTERN SHORE BROKERS, LLC
Entity type:Organization
Organization Name:EASTERN SHORE BROKERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CASE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-614-8873
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:WHALEYVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21872-0123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12641 BLUEBERRY RD
Practice Address - Street 2:
Practice Address - City:WHALEYVILLE
Practice Address - State:MD
Practice Address - Zip Code:21872-2013
Practice Address - Country:US
Practice Address - Phone:410-726-2967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services