Provider Demographics
NPI:1407562911
Name:PUSH HEALTH AND WELLNESS, LLC
Entity Type:Organization
Organization Name:PUSH HEALTH AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:T
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-690-8029
Mailing Address - Street 1:1321 MOUNT HERMON RD # C-1
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1321 MOUNT HERMON RD # C-1
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5302
Practice Address - Country:US
Practice Address - Phone:443-736-8691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD22111353OtherBHA LICENSE NUMBER -PRP