=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013142066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMELLIA HOME HEALTH OF THE GULF COAST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2009
-----------------------------------------------------
Last Update Date | 12/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 360 COURTHOUSE RD STE E
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39507-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-374-2273
-----------------------------------------------------
Fax | 228-432-0522
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6688 N CENTRAL EXPY STE 1300
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75206-3950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-239-6500
-----------------------------------------------------
Fax | 214-239-6581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP OF HOME HEALTH OPERATIONS
-----------------------------------------------------
Name | JULIE DIANE JOLLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-239-6500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------