Provider Demographics
NPI:1790378586
Name:PROTELIX HEALTH CLINIC LLC
Entity Type:Organization
Organization Name:PROTELIX HEALTH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:THELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAINE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C
Authorized Official - Phone:410-575-4494
Mailing Address - Street 1:1810J YORK RD STE 178
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5118
Mailing Address - Country:US
Mailing Address - Phone:410-575-4494
Mailing Address - Fax:
Practice Address - Street 1:22 W PADONIA RD STE C133
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2238
Practice Address - Country:US
Practice Address - Phone:410-575-4494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-12
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1558629246Medicaid