Provider Demographics
NPI:1760545057
Name:WESCO INDUSTRIES
Entity Type:Organization
Organization Name:WESCO INDUSTRIES
Other - Org Name:CAMELOT SQUARE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-263-6141
Mailing Address - Street 1:415 S 11TH ST
Mailing Address - Street 2:P.O. BOX 340
Mailing Address - City:DENISON
Mailing Address - State:IA
Mailing Address - Zip Code:51442-2451
Mailing Address - Country:US
Mailing Address - Phone:712-263-6141
Mailing Address - Fax:712-263-4886
Practice Address - Street 1:415 S 11TH ST
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:IA
Practice Address - Zip Code:51442-2451
Practice Address - Country:US
Practice Address - Phone:712-263-6141
Practice Address - Fax:712-263-4886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0228346Medicaid
IA0893248Medicaid
IA0120535Medicaid