Healthcare Provider Details

I. General information

NPI: 1477365849
Provider Name (Legal Business Name): IDEAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3914 HICKORY AVE
BALTIMORE MD
21211-1834
US

IV. Provider business mailing address

3914 HICKORY AVE
BALTIMORE MD
21211-1834
US

V. Phone/Fax

Practice location:
  • Phone: 410-916-6888
  • Fax: 410-662-9884
Mailing address:
  • Phone: 410-916-6888
  • Fax: 410-662-9884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL DORN
Title or Position: CEO/OWNER
Credential:
Phone: 410-916-6888