Provider Demographics
NPI:1609663368
Name:GREY PHOENIX LLC
Entity type:Organization
Organization Name:GREY PHOENIX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:OLADIPUPO
Authorized Official - Middle Name:
Authorized Official - Last Name:ADENUBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-681-9190
Mailing Address - Street 1:2689 ORCHARD ORIOLE WAY
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-3120
Mailing Address - Country:US
Mailing Address - Phone:202-681-9190
Mailing Address - Fax:
Practice Address - Street 1:2689 ORCHARD ORIOLE WAY
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-3120
Practice Address - Country:US
Practice Address - Phone:202-681-9190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREY PHOENIX LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-04-24
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care