Provider Demographics
NPI:1730966169
Name:FREE BALTIMORE, LLC
Entity type:Organization
Organization Name:FREE BALTIMORE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:NORTHWEST
Authorized Official - Middle Name:REGISTERED
Authorized Official - Last Name:AGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-768-2249
Mailing Address - Street 1:1120 N CHARLES ST STE 303
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3261 OLD WASHINGTON RD STE 2020
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3231
Practice Address - Country:US
Practice Address - Phone:240-229-6417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREE BALTIMORE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-11
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities