Provider Demographics
NPI:1912681883
Name:VITALITY 360 OF BALTIMORE AT PROVIDENCE
Entity Type:Organization
Organization Name:VITALITY 360 OF BALTIMORE AT PROVIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:CHIMERE
Authorized Official - Middle Name:
Authorized Official - Last Name:BECOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-606-6424
Mailing Address - Street 1:4001 SEVEN MILE LN
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1427 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-3135
Practice Address - Country:US
Practice Address - Phone:443-606-6424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care