Provider Demographics
NPI:1699407502
Name:WELLVANA MARYLAND, LLC
Entity Type:Organization
Organization Name:WELLVANA MARYLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-378-7336
Mailing Address - Street 1:4840 CENTENNIAL BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-1792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4840 CENTENNIAL BLVD STE 202
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-1792
Practice Address - Country:US
Practice Address - Phone:860-501-7908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLVANA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization