Healthcare Provider Details

I. General information

NPI: 1275368680
Provider Name (Legal Business Name): KINGS HEART RECOVERY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 E 25TH ST
BALTIMORE MD
21218-5503
US

IV. Provider business mailing address

920 E 25TH ST
BALTIMORE MD
21218-5503
US

V. Phone/Fax

Practice location:
  • Phone: 443-793-8485
  • Fax:
Mailing address:
  • Phone: 443-793-8485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL
# 10
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHANTIA BEAN
Title or Position: OWNER
Credential:
Phone: 443-793-8485