Provider Demographics
NPI:1265752620
Name:IDA MAE CAMPBELL WELLNESS & RESOURCE CENTER
Entity type:Organization
Organization Name:IDA MAE CAMPBELL WELLNESS & RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:IDEN
Authorized Official - Middle Name:DONOVAN
Authorized Official - Last Name:CAMPBELL-MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-684-7015
Mailing Address - Street 1:1338 N CAPITOL ST NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3337
Mailing Address - Country:US
Mailing Address - Phone:202-684-7015
Mailing Address - Fax:866-666-0251
Practice Address - Street 1:1338 N CAPITOL ST NW
Practice Address - Street 2:SUITE 101
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-3337
Practice Address - Country:US
Practice Address - Phone:202-684-7015
Practice Address - Fax:866-666-0251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251X00000XAgenciesSupports Brokerage