Healthcare Provider Details

I. General information

NPI: 1467158998
Provider Name (Legal Business Name): WELLNESS EGO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12820 RIVER RD STE HGH
POTOMAC MD
20854-1139
US

IV. Provider business mailing address

9812 FALLS RD STE 114-324
POTOMAC MD
20854-3976
US

V. Phone/Fax

Practice location:
  • Phone: 240-762-1279
  • Fax:
Mailing address:
  • Phone: 240-762-1279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHUANNA TONI MONCRIEFFE
Title or Position: OWNER/CONSULTANT
Credential: MSCEM, NASM-CNC
Phone: 301-974-1425