Provider Demographics
NPI:1184164014
Name:ELAINE ELLIS CENTER OF HEALTH
Entity type:Organization
Organization Name:ELAINE ELLIS CENTER OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-441-1605
Mailing Address - Street 1:10001 RHODE ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-1141
Mailing Address - Country:US
Mailing Address - Phone:301-441-1605
Mailing Address - Fax:301-345-1609
Practice Address - Street 1:10001 RHODE ISLAND AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1141
Practice Address - Country:US
Practice Address - Phone:301-441-1605
Practice Address - Fax:301-345-1609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-25
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QD0000X
DC400312000595261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD500072600Medicaid
DC082390200Medicaid
091844Medicare PIN