Provider Demographics
NPI:1972861193
Name:OUR FAMILY TREE
Entity type:Organization
Organization Name:OUR FAMILY TREE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / C.E.O
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:DISTANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-608-0401
Mailing Address - Street 1:1203 LAKESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218
Mailing Address - Country:US
Mailing Address - Phone:443-608-0401
Mailing Address - Fax:410-243-2246
Practice Address - Street 1:1203 LAKESIDE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-3002
Practice Address - Country:US
Practice Address - Phone:443-608-0401
Practice Address - Fax:410-243-2246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR3139253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care