Healthcare Provider Details

I. General information

NPI: 1871088682
Provider Name (Legal Business Name): COMPASSIONATE WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 N POTOMAC ST STE 101&102
HAGERSTOWN MD
21740-4855
US

IV. Provider business mailing address

10319 WESTLAKE DR STE 335
BETHESDA MD
20817-6403
US

V. Phone/Fax

Practice location:
  • Phone: 240-513-6001
  • Fax: 240-513-6122
Mailing address:
  • Phone: 240-513-6001
  • Fax: 240-513-6122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD70102
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberD70102
License Number StateMD

VIII. Authorized Official

Name: DR. IVAN NGANG ZAMA
Title or Position: PRESIDENT
Credential: MD
Phone: 240-513-6001