Organization
DIVINE LIGHT RESIDENTIAL TREATMENT LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SAKINA DEAN (CHIEF EXECUTIVE OFFICER)
(267) 278-1079
Entity
Organization
Contact information
Practice address
1200 W BALTIMORE ST, BALTIMORE, MD 21223-2601
(267) 278-1079
Mailing address
1200 W BALTIMORE ST, BALTIMORE, MD 21223-2601
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
577023800
—
MD
Enumeration date
05/03/2022
Last updated
05/03/2022
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