Healthcare Provider Details

I. General information

NPI: 1265752620
Provider Name (Legal Business Name): IDA MAE CAMPBELL WELLNESS & RESOURCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 N CAPITOL ST NW SUITE 101
WASHINGTON DC
20002-3337
US

IV. Provider business mailing address

1338 N CAPITOL ST NW SUITE 101
WASHINGTON DC
20002-3337
US

V. Phone/Fax

Practice location:
  • Phone: 202-684-7015
  • Fax: 866-666-0251
Mailing address:
  • Phone: 202-684-7015
  • Fax: 866-666-0251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. IDEN DONOVAN CAMPBELL-MCCOLLUM
Title or Position: CEO/FOUNDER
Credential:
Phone: 202-684-7015