Healthcare Provider Details

I. General information

NPI: 1205542701
Provider Name (Legal Business Name): MARYLAND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4128 HAYWARD AVE # W
BALTIMORE MD
21215-4340
US

IV. Provider business mailing address

4128 HAYWARD AVE # W
BALTIMORE MD
21215-4340
US

V. Phone/Fax

Practice location:
  • Phone: 410-314-1030
  • Fax:
Mailing address:
  • Phone: 410-314-1030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CASEY WU
Title or Position: DIRECTOR
Credential:
Phone: 214-659-1503