Provider Demographics
NPI:1194583146
Name:IDAS PLACE LLC
Entity type:Organization
Organization Name:IDAS PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:E
Authorized Official - Last Name:LIVERPOOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-710-3061
Mailing Address - Street 1:583 FREDERICK RD STE 3A
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4697
Mailing Address - Country:US
Mailing Address - Phone:443-710-3061
Mailing Address - Fax:410-747-5001
Practice Address - Street 1:583 FREDERICK RD STE 3A
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4697
Practice Address - Country:US
Practice Address - Phone:443-710-3061
Practice Address - Fax:410-747-5001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-13
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder