Healthcare Provider Details

I. General information

NPI: 1164776738
Provider Name (Legal Business Name): CAMELOT PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 CROWLEY RAYNE HWY
RAYNE LA
70578-4027
US

IV. Provider business mailing address

4333 SHREVEPORT HWY
PINEVILLE LA
71360-3828
US

V. Phone/Fax

Practice location:
  • Phone: 337-783-8101
  • Fax: 888-641-3781
Mailing address:
  • Phone: 318-445-6470
  • Fax: 318-641-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: NICOLE HOWARD
Title or Position: C.F.O. / C.O.O.
Credential:
Phone: 318-641-3717