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General NPI Number Information
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NPI Number | 1144716192
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Entity Type | Organization
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Legal Business Name | GUADALUPE CENTER FOR HEALING
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Dates
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Enumeration Date | 07/02/2018
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Last Update Date | 01/24/2024
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Provider Practice Location Address
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Address Line | 1643 LIBERTY RD STE 105
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City | ELDERSBURG
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State | MD
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Zip | 21784-6545
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Country | US
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Telephone | 478-250-7092
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Fax |
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Provider Business Mailing Address
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Address Line | 717 COLLIER CT
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City | WESTMINSTER
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State | MD
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Zip | 21158-9449
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Country | US
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Telephone | 478-250-7092
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MARJORIE R LIVINGSTON
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Credential | CRNP
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Telephone | 478-250-7092
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | W18924431
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License Number State | MD
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