Provider Demographics
NPI:1932765146
Name:BALM OF GILEAD HEALTH & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:BALM OF GILEAD HEALTH & WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHINWE
Authorized Official - Middle Name:
Authorized Official - Last Name:OKUDO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C, PMHN-BC
Authorized Official - Phone:301-655-2927
Mailing Address - Street 1:9863 DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-3776
Mailing Address - Country:US
Mailing Address - Phone:301-655-2927
Mailing Address - Fax:
Practice Address - Street 1:107 BEACON RD
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-3504
Practice Address - Country:US
Practice Address - Phone:443-868-7405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1730639535Medicaid
MDN90612OtherCDS
MDR198702OtherMBON
MDR198702OtherMBON