1144430109 NPI number — CAMELOT SENIOR LIVING, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144430109 NPI number — CAMELOT SENIOR LIVING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMELOT SENIOR LIVING, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144430109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8716 MILO CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95624-1817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-803-1955
Provider Business Mailing Address Fax Number:
916-685-6343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9237 CROSSCOURT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95624-3919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-803-1955
Provider Business Practice Location Address Fax Number:
916-685-6343
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAHLQUIST
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
EMERSON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-803-1955

Provider Taxonomy Codes

  • Taxonomy code: 311Z00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RCF00026F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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