Provider Demographics
NPI:1942977244
Name:SUMMIT HOLISTIC CENTER LLC
Entity type:Organization
Organization Name:SUMMIT HOLISTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NJIDEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:UDOCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-245-2414
Mailing Address - Street 1:6310 STEVENS FOREST RD STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1036
Mailing Address - Country:US
Mailing Address - Phone:410-245-2414
Mailing Address - Fax:410-740-9005
Practice Address - Street 1:6310 STEVENS FOREST RD STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1036
Practice Address - Country:US
Practice Address - Phone:410-245-2414
Practice Address - Fax:410-740-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0051897OtherSTATE LICENSE
MD685900300Medicaid