Provider Demographics
NPI:1467278812
Name:WELLSPRINGS RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:WELLSPRINGS RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER, CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:BAFONGO-IKOMBE
Authorized Official - Last Name:ZULU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-756-9206
Mailing Address - Street 1:30 LYDIA LN UNIT 284
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2379
Mailing Address - Country:US
Mailing Address - Phone:207-756-9206
Mailing Address - Fax:
Practice Address - Street 1:30 LYDIA LN UNIT 284
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2379
Practice Address - Country:US
Practice Address - Phone:207-756-9206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities