Healthcare Provider Details

I. General information

NPI: 1588293138
Provider Name (Legal Business Name): BMOREYOUTHFUL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 DUSK VIEW DR
HAVRE DE GRACE MD
21078-2369
US

IV. Provider business mailing address

517 DUSK VIEW DR
HAVRE DE GRACE MD
21078-2369
US

V. Phone/Fax

Practice location:
  • Phone: 443-902-1364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN WEST
Title or Position: PROVIDER
Credential:
Phone: 443-902-1364