Provider Demographics
NPI:1558620708
Name:BALTIMORE COMMUNITY RESOURCE CENTER, INC
Entity Type:Organization
Organization Name:BALTIMORE COMMUNITY RESOURCE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-366-1717
Mailing Address - Street 1:21 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5003
Mailing Address - Country:US
Mailing Address - Phone:410-366-1717
Mailing Address - Fax:410-889-4167
Practice Address - Street 1:3623 PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1326
Practice Address - Country:US
Practice Address - Phone:410-366-1717
Practice Address - Fax:410-889-4167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD903995324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD417128400Medicaid