MEDICARE: CAMP CAMP CAMPER HOLDING GROUP 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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1184557431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMP CAMP CAMPER HOLDING GROUP LLC

Provider Business Mailing Address
First Line	:	3738 W CENTURY BLVD STE 5
Second Line	:
City	:	INGLEWOOD
State	:	CA
Zip	:	90303-1180
Country	:	US
Telephone Number	:	310-709-6541
Fax Number	:

Provider Business Practice Location Address
First Line	:	3738 W CENTURY BLVD STE 5
Second Line	:
City	:	INGLEWOOD
State	:	CA
Zip	:	90303-1180
Country	:	US
Telephone Number	:	310-709-6541
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DERRICK ALLEN
Credential	:
Telephone Number	:	310-709-6541

Provider Enumeration Date	:	06/05/2026
Last Update Date	:	06/05/2026

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