Healthcare Provider Details

I. General information

NPI: 1740510338
Provider Name (Legal Business Name): CAMELOT CARE CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2144 S MACARTHUR BLVD
SPRINGFIELD IL
62704-4502
US

IV. Provider business mailing address

333 W PIERCE RD STE 175
ITASCA IL
60143-3120
US

V. Phone/Fax

Practice location:
  • Phone: 217-585-9185
  • Fax: 217-585-8522
Mailing address:
  • Phone: 217-585-9185
  • Fax: 217-585-8522

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: RONICA R PATEL
Title or Position: STATE EXECUTIVE DIRECTOR
Credential:
Phone: 630-773-1985