Provider Demographics
NPI:1215689294
Name:LEAD 4 LIFE, INC.
Entity type:Organization
Organization Name:LEAD 4 LIFE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-978-7864
Mailing Address - Street 1:2096 GAITHER RD STE 110
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4027
Mailing Address - Country:US
Mailing Address - Phone:301-672-4319
Mailing Address - Fax:
Practice Address - Street 1:100 CLEMWOOD ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6489
Practice Address - Country:US
Practice Address - Phone:443-978-7864
Practice Address - Fax:443-859-8880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEAD4LIFE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD201507201Medicaid