Healthcare Provider Details

I. General information

NPI: 1659287175
Provider Name (Legal Business Name): BISA WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 MAIN ST
PRINCE FREDERICK MD
20678-3186
US

IV. Provider business mailing address

493 MAIN ST
PRINCE FREDERICK MD
20678-3186
US

V. Phone/Fax

Practice location:
  • Phone: 208-409-2566
  • Fax:
Mailing address:
  • Phone: 208-409-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ENDYSEN ATU
Title or Position: DIRECTOR
Credential:
Phone: 208-409-2566