Provider Demographics
NPI:1174298236
Name:MONTGOMERY WELLNESS HUB LLC
Entity Type:Organization
Organization Name:MONTGOMERY WELLNESS HUB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:KOLAWOLE
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-404-7336
Mailing Address - Street 1:951 RUSSELL AVE STE D
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3283
Mailing Address - Country:US
Mailing Address - Phone:301-404-7336
Mailing Address - Fax:
Practice Address - Street 1:951 RUSSELL AVE STE D
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3283
Practice Address - Country:US
Practice Address - Phone:301-404-7336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)