1912440793 NPI number — TRUE WELLNESS LLC

Table of content: (NPI 1912440793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912440793 NPI number — TRUE WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRUE WELLNESS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912440793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 501
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20658-0501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-861-3454
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4570 BICKNELL RD
Provider Second Line Business Practice Location Address:
#501
Provider Business Practice Location Address City Name:
MARBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20658-9998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-861-3454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ASHE
Authorized Official First Name:
SHANTE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
EXECUTIVE DIRECTOR & THERAPIST
Authorized Official Telephone Number:
301-861-3454

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 051354700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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