Basic Information
| Provider Information | |||||||||
| NPI: | 1932707395 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLCARE INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5446 N ACADEMY BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195985555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5446 N ACADEMY BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195985555 | ||||||||
| FaxNumber: | 7193882030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2020 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | DAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CFO | ||||||||
| AuthorizedOfficialTelephone: | 7195985555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELLCARE INC. | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.