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General NPI Number Information
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NPI Number | 1265628440
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Entity Type | Organization
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Legal Business Name | CAMELOT OF VIRGINIA, LLC
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Dates
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Enumeration Date | 09/20/2007
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Last Update Date | 09/20/2007
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Provider Practice Location Address
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Address Line | 5978 BELSPRINGS RD.
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City | RADFORD
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State | VA
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Zip | 24141
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Country | US
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Telephone | 540-639-1688
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Fax |
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Provider Business Mailing Address
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Address Line | 4207 E HIGHWAY 290
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City | DRIPPING SPRINGS
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State | TX
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Zip | 78620-4206
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Country | US
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Telephone | 512-858-9900
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Fax |
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Authorized Official
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Title or Position | BUSINESS OFFICE DIRECTOR
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Name | GRAYSON HARCOURT
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Credential |
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Telephone | 512-858-9900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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