Healthcare Provider Details

I. General information

NPI: 1689943078
Provider Name (Legal Business Name): CAMELOT BROOKSIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 N FRONTAGE RD
JENNINGS LA
70546-3269
US

IV. Provider business mailing address

4333 SHREVEPORT HWY
PINEVILLE LA
71360-3828
US

V. Phone/Fax

Practice location:
  • Phone: 337-824-2466
  • Fax:
Mailing address:
  • Phone: 318-445-6470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: NICOLE HOWARD
Title or Position: C.O.O.
Credential:
Phone: 318-445-6470