Healthcare Provider Details

I. General information

NPI: 1780933861
Provider Name (Legal Business Name): CAMELOT COMMUNITY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6416 MELALEUCA LANE
GREENACRES FL
33464
US

IV. Provider business mailing address

6416 MELALEUCA LANE
GREENACRES FL
33464
US

V. Phone/Fax

Practice location:
  • Phone: 561-649-0877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. LESLIE SERENA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 561-649-0877