Provider Demographics
NPI:1871330233
Name:GLENSAN WELLNESS AND LASER PAIN CENTER
Entity type:Organization
Organization Name:GLENSAN WELLNESS AND LASER PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOSUNMOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-263-4890
Mailing Address - Street 1:10801 GREEN ASH LN
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3851
Mailing Address - Country:US
Mailing Address - Phone:301-263-4890
Mailing Address - Fax:
Practice Address - Street 1:216 CRAIN HWY N STE 103
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3079
Practice Address - Country:US
Practice Address - Phone:301-272-1558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation