Provider Demographics
NPI:1043926561
Name:MARYLAND WELLNESS LLC
Entity Type:Organization
Organization Name:MARYLAND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-659-1503
Mailing Address - Street 1:4128 HAYWARD AVE # W
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4340
Mailing Address - Country:US
Mailing Address - Phone:410-314-1030
Mailing Address - Fax:410-314-1030
Practice Address - Street 1:519 N MECHANIC ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2133
Practice Address - Country:US
Practice Address - Phone:410-314-1030
Practice Address - Fax:410-314-1030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD220412450OtherMARYLAND DEPARTMENT OF HEALTH