Provider Demographics
NPI:1437830759
Name:EXPRESS MEDICAL WELLNESS LLC
Entity Type:Organization
Organization Name:EXPRESS MEDICAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NEEKO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-203-8898
Mailing Address - Street 1:1000 GOODWILL AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-2972
Mailing Address - Country:US
Mailing Address - Phone:443-972-4204
Mailing Address - Fax:201-361-5368
Practice Address - Street 1:1000 GOODWILL AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2972
Practice Address - Country:US
Practice Address - Phone:443-203-8898
Practice Address - Fax:201-361-5368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-28
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty