Provider Demographics
NPI:1346637550
Name:MARYLAND HEALTH, WELLNESS, AND REHABILITATION, LLC
Entity Type:Organization
Organization Name:MARYLAND HEALTH, WELLNESS, AND REHABILITATION, LLC
Other - Org Name:MDWELLNESSANDREHAB
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROEL MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-332-2490
Mailing Address - Street 1:7542 RAIN FLOWER WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-2438
Mailing Address - Country:US
Mailing Address - Phone:602-332-2490
Mailing Address - Fax:
Practice Address - Street 1:7542 RAIN FLOWER WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2438
Practice Address - Country:US
Practice Address - Phone:602-332-2490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-26
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty