Healthcare Provider Details

I. General information

NPI: 1861801573
Provider Name (Legal Business Name): CAMELOT RESIDENTIAL HOMES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8324 CRESCENT AVE
BUENA PARK CA
90620-4024
US

IV. Provider business mailing address

8324 CRESCENT AVE
BUENA PARK CA
90620-4024
US

V. Phone/Fax

Practice location:
  • Phone: 714-827-0482
  • Fax:
Mailing address:
  • Phone: 714-827-0482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number198205266
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number198205266
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number198205266
License Number StateCA

VIII. Authorized Official

Name: MR. JEFFERSON AQUINO BAUTISTA
Title or Position: PRESIDENT
Credential: N.P.
Phone: 714-827-0482