Provider Demographics
NPI:1154639243
Name:ANNMARIE CAMPBELL ADULT FAMILY CARE HOME
Entity Type:Organization
Organization Name:ANNMARIE CAMPBELL ADULT FAMILY CARE HOME
Other - Org Name:CAMPBELLS ADULT FAMILY CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-554-2916
Mailing Address - Street 1:320 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1835
Mailing Address - Country:US
Mailing Address - Phone:954-554-2916
Mailing Address - Fax:
Practice Address - Street 1:320 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1835
Practice Address - Country:US
Practice Address - Phone:954-554-2916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906326310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001098700Medicaid