Provider Demographics
NPI:1740716422
Name:AVAYA HEALTH SERVICES OF MARYLAND, LLC
Entity type:Organization
Organization Name:AVAYA HEALTH SERVICES OF MARYLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-454-1672
Mailing Address - Street 1:1735 HECKLE BLVD
Mailing Address - Street 2:STE. 103-262
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-4803
Mailing Address - Country:US
Mailing Address - Phone:919-454-1672
Mailing Address - Fax:
Practice Address - Street 1:1812 GUILFORD AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2833
Practice Address - Country:US
Practice Address - Phone:919-454-1672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health