Healthcare Provider Details

I. General information

NPI: 1336685908
Provider Name (Legal Business Name): CAMELOT FAMILY HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E SWANSON AVE STE 3
WASILLA AK
99654-7197
US

IV. Provider business mailing address

500 E SWANSON AVE STE 3
WASILLA AK
99654-7197
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-6180
  • Fax: 907-357-6184
Mailing address:
  • Phone: 907-357-6180
  • Fax: 907-357-6184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1009915
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: DAVID R CHISHOLM
Title or Position: OWNER
Credential: M.D.
Phone: 907-357-6180