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General NPI Number Information
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NPI Number | 1659044162
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Entity Type | Organization
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Legal Business Name | MOCO WELLNESS
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Dates
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Enumeration Date | 07/29/2021
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Last Update Date | 03/08/2022
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Provider Practice Location Address
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Address Line | 6517 PERSIMMON TREE RD
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City | CABIN JOHN
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State | MD
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Zip | 20818-1216
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Country | US
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Telephone | 773-746-2964
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 736198
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City | DALLAS
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State | TX
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Zip | 75373-6198
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Country | US
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Telephone | 773-746-2964
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. BRETT WALTERS
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Credential | MD
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Telephone | 773-746-2964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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