Healthcare Provider Details

I. General information

NPI: 1285266262
Provider Name (Legal Business Name): MONTGOMERY WELLNESS HUB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 RUSSELL AVE STE D
GAITHERSBURG MD
20879-3283
US

IV. Provider business mailing address

951 RUSSELL AVE STE D
GAITHERSBURG MD
20879-3283
US

V. Phone/Fax

Practice location:
  • Phone: 301-404-7336
  • Fax:
Mailing address:
  • Phone: 301-404-7336
  • Fax: 240-246-7911

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: MOHAMMED KOLAWOLE IBRAHIM
Title or Position: CEO
Credential:
Phone: 301-404-7336