Provider Demographics
NPI:1154868727
Name:LICE CLINICS OF MARYLAND, LLC
Entity type:Organization
Organization Name:LICE CLINICS OF MARYLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:UPDIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-934-5423
Mailing Address - Street 1:604 PROVIDENCE ROAD
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286
Mailing Address - Country:US
Mailing Address - Phone:410-934-5423
Mailing Address - Fax:
Practice Address - Street 1:604 PROVIDENCE ROAD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286
Practice Address - Country:US
Practice Address - Phone:410-934-5423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03003633261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center