Provider Demographics
NPI:1366953416
Name:VASTLAND, LLC
Entity type:Organization
Organization Name:VASTLAND, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WELLINGTON
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-460-0403
Mailing Address - Street 1:6106 EDMONDSON AVE STE 102&105
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1830
Mailing Address - Country:US
Mailing Address - Phone:202-460-0403
Mailing Address - Fax:301-965-8625
Practice Address - Street 1:6106 EDMONDSON AVE STE 102&105
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-1830
Practice Address - Country:US
Practice Address - Phone:202-460-0403
Practice Address - Fax:301-965-8625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR4101251J00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5002575-00Medicaid