=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013716166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLSPRING BRIDGE HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2025
-----------------------------------------------------
Last Update Date | 04/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1451 ROCKVILLE PIKE STE 250
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-1486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-640-5288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1451 ROCKVILLE PIKE STE 250
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-1486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-640-5288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MOMOH MAKIEU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-640-5288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------