Provider Demographics
NPI:1851150833
Name:MANIFEST WELLNESS SERVICES LLC
Entity Type:Organization
Organization Name:MANIFEST WELLNESS SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:IFEANYICHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-531-4264
Mailing Address - Street 1:6008 PLUMER AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-2759
Mailing Address - Country:US
Mailing Address - Phone:443-531-4264
Mailing Address - Fax:
Practice Address - Street 1:6340 SECURITY BLVD STE B16
Practice Address - Street 2:
Practice Address - City:WOODLAWN
Practice Address - State:MD
Practice Address - Zip Code:21207-5173
Practice Address - Country:US
Practice Address - Phone:443-531-4264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty