Healthcare Provider Details

I. General information

NPI: 1700149051
Provider Name (Legal Business Name): CAMELOT CARE CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2396 W NEBRASKA AVE
PEORIA IL
61604-3111
US

IV. Provider business mailing address

2396 W NEBRASKA AVE
PEORIA IL
61604-3111
US

V. Phone/Fax

Practice location:
  • Phone: 309-676-6305
  • Fax: 309-676-6519
Mailing address:
  • Phone: 309-676-6305
  • Fax: 309-676-6519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. RONICA PATEL
Title or Position: STATE EXECUTIVE DIRECTOR
Credential:
Phone: 630-773-1985