Healthcare Provider Details

I. General information

NPI: 1699047548
Provider Name (Legal Business Name): CAMELOT OF STATEN ISLAND INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17515 ROCKAWAY BLVD
JAMAICA NY
11434-5503
US

IV. Provider business mailing address

17515 ROCKAWAY BLVD
JAMAICA NY
11434-5503
US

V. Phone/Fax

Practice location:
  • Phone: 718-632-3275
  • Fax: 718-632-7952
Mailing address:
  • Phone: 718-632-3275
  • Fax: 718-632-7952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LUKE NASTA
Title or Position: EXECUTIVE DIRECTOR
Credential: MPA, CASAC
Phone: 718-981-8117