=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386181311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYERS HEALTH AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2017
-----------------------------------------------------
Last Update Date | 01/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3512 SANDPIPER CT
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21040-3736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-866-7504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3512 SANDPIPER CT
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21040-3736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-866-7504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | QUINTON MYERS
-----------------------------------------------------
Credential | CRNP-PMH
-----------------------------------------------------
Telephone | 443-866-7504
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 5000000000741693
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------