Provider Demographics
NPI:1285472985
Name:AGILE PRIMARY CARE AND REHABILITATION SERVICES
Entity type:Organization
Organization Name:AGILE PRIMARY CARE AND REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOSUNMOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-263-4890
Mailing Address - Street 1:216 CRAIN HWY N STE 102
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 CRAIN HWY N STE 102
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3086
Practice Address - Country:US
Practice Address - Phone:301-263-4890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No251E00000XAgenciesHome Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care