=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568064764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVAWELL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2020
-----------------------------------------------------
Last Update Date | 11/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1308 BUSINESS CENTER WAY STE 101
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21040-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-676-0841
-----------------------------------------------------
Fax | 410-676-0950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1308 BUSINESS CENTER WAY STE 101
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21040-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-676-0841
-----------------------------------------------------
Fax | 410-676-0950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES OMOTOSHO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-992-5088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------