Healthcare Provider Details

I. General information

NPI: 1437972924
Provider Name (Legal Business Name): MONTGOMERY WELLNESS HUB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 W WASHINGTON ST STE 200
HAGERSTOWN MD
21740-4830
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 TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MOHAMMED KOLAWOLE IBRAHIM
Title or Position: CEO
Credential:
Phone: 240-246-7837