Provider Demographics
NPI:1043043201
Name:BROAD PLACE, INC
Entity type:Organization
Organization Name:BROAD PLACE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABIMBOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNSEWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-360-3693
Mailing Address - Street 1:902 WASHINGTON RD STE G
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5832
Mailing Address - Country:US
Mailing Address - Phone:240-360-3693
Mailing Address - Fax:443-405-7237
Practice Address - Street 1:902 WASHINGTON RD STE G
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5832
Practice Address - Country:US
Practice Address - Phone:240-360-3693
Practice Address - Fax:443-405-7237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health