Provider Demographics
NPI:1154459949
Name:BERKELEY WELLNESS ASSOCIATES
Entity Type:Organization
Organization Name:BERKELEY WELLNESS ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:BRADFORD
Authorized Official - Last Name:BERKELEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:240-476-5684
Mailing Address - Street 1:1922 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1908
Mailing Address - Country:US
Mailing Address - Phone:410-721-2714
Mailing Address - Fax:
Practice Address - Street 1:3327 SUPERIOR LN
Practice Address - Street 2:SUITE 204
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1922
Practice Address - Country:US
Practice Address - Phone:301-860-0288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02187261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service