Provider Demographics
NPI:1366226821
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:443-416-5667
Mailing Address - Street 1:1120 N CHARLES ST STE 408
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5594
Mailing Address - Country:US
Mailing Address - Phone:443-416-5667
Mailing Address - Fax:
Practice Address - Street 1:411 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2421
Practice Address - Country:US
Practice Address - Phone:240-229-6417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREE BALTIMORE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)