Healthcare Provider Details

I. General information

NPI: 1871330233
Provider Name (Legal Business Name): GLENSAN WELLNESS AND LASER PAIN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 CRAIN HWY N STE 103
GLEN BURNIE MD
21061-3079
US

IV. Provider business mailing address

10801 GREEN ASH LN
BELTSVILLE MD
20705-3851
US

V. Phone/Fax

Practice location:
  • Phone: 301-272-1558
  • Fax:
Mailing address:
  • Phone: 301-263-4890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOSUNMOLA LAKE
Title or Position: MANAGER
Credential:
Phone: 301-263-4890