1679797492 NPI number — CAMELOT COMMUNITY CARE, INC

Table of content: (NPI 1679797492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679797492 NPI number — CAMELOT COMMUNITY CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMELOT COMMUNITY CARE, 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:
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:
1679797492
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4910 CREEKSIDE DR STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33760-4034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-593-0003
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 NE 25TH AVE
Provider Second Line Business Practice Location Address:
SUTIE 306
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34470-8800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-671-7884
Provider Business Practice Location Address Fax Number:
352-671-7379
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
JANA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF AR
Authorized Official Telephone Number:
727-593-0003

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 070594200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com