Healthcare Provider Details

I. General information

NPI: 1639987894
Provider Name (Legal Business Name): FMW MEDSPA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 WEST RD STE 210
TOWSON MD
21204-2341
US

IV. Provider business mailing address

110 WEST RD STE 210
TOWSON MD
21204-2341
US

V. Phone/Fax

Practice location:
  • Phone: 443-840-9478
  • Fax: 410-616-9048
Mailing address:
  • Phone: 443-840-9478
  • Fax: 410-616-9048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State

VIII. Authorized Official

Name: LINETTE I EKE
Title or Position: PROVIDER
Credential:
Phone: 443-840-9478