Provider Demographics
NPI:1831443787
Name:WELLSPRING CLINIC LLC
Entity type:Organization
Organization Name:WELLSPRING CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NKIRUKA
Authorized Official - Middle Name:
Authorized Official - Last Name:ARENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-371-9750
Mailing Address - Street 1:2012 S TOLLGATE RD STE 207
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-5902
Mailing Address - Country:US
Mailing Address - Phone:443-371-9750
Mailing Address - Fax:443-371-9751
Practice Address - Street 1:2012 S TOLLGATE RD STE 207
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-5902
Practice Address - Country:US
Practice Address - Phone:443-371-9750
Practice Address - Fax:443-371-9751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 2081P0301X, 2081P2900X, 208100000X
MDD63924261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty