Provider Demographics
NPI:1497349997
Name:BLUE SPRING WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:BLUE SPRING WELLNESS CENTER LLC
Other - Org Name:BLUE SPRING WELLNESS CENTER LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOTENESIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NJOROGE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP-PMH
Authorized Official - Phone:410-456-5812
Mailing Address - Street 1:8 HALLSDALE CT
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-5009
Mailing Address - Country:US
Mailing Address - Phone:410-456-5812
Mailing Address - Fax:
Practice Address - Street 1:807 EAST BALTIMORE ST, UNIT 1A,
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-5388
Practice Address - Country:US
Practice Address - Phone:410-456-5812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-24
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0000000Medicaid
MD5424780900Medicaid