MEDICARE: PRIMARY HEALTH & WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	D0057313	MD

General Provider Information

NPI Number	:	1225274061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY HEALTH & WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	9055 CHEVROLET DR
Second Line	:	SUITE 103
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-4016
Country	:	US
Telephone Number	:	410-465-7850
Fax Number	:	410-465-3716

Provider Business Practice Location Address
First Line	:	9055 CHEVROLET DR
Second Line	:	SUITE 103
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-4016
Country	:	US
Telephone Number	:	410-465-7850
Fax Number	:	410-465-3716

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MITUL DAVE
Credential	:	MD
Telephone Number	:	410-465-7850

Provider Enumeration Date	:	12/29/2008
Last Update Date	:	01/27/2010

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