Provider Demographics
NPI:1912763996
Name:HERITAGE OF PISON INC
Entity Type:Organization
Organization Name:HERITAGE OF PISON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OLADOTUN
Authorized Official - Middle Name:OLAREWAJU
Authorized Official - Last Name:OLUWAGBOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-432-8470
Mailing Address - Street 1:909 BALTIMORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-7064
Mailing Address - Country:US
Mailing Address - Phone:443-432-8470
Mailing Address - Fax:
Practice Address - Street 1:909 BALTIMORE BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-7064
Practice Address - Country:US
Practice Address - Phone:443-432-8470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities