Provider Demographics
NPI:1477157857
Name:BMOREYOUTHFUL LLC
Entity Type:Organization
Organization Name:BMOREYOUTHFUL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:443-902-1364
Mailing Address - Street 1:517 DUSK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-2369
Mailing Address - Country:US
Mailing Address - Phone:443-902-1364
Mailing Address - Fax:
Practice Address - Street 1:517 DUSK VIEW DR
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-2369
Practice Address - Country:US
Practice Address - Phone:443-902-1364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty