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General NPI Number Information
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NPI Number | 1861801573
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Entity Type | Organization
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Legal Business Name | CAMELOT RESIDENTIAL HOMES, INC.
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Dates
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Enumeration Date | 08/06/2014
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Last Update Date | 08/06/2014
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Provider Practice Location Address
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Address Line | 8324 CRESCENT AVE
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City | BUENA PARK
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State | CA
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Zip | 90620-4024
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Country | US
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Telephone | 714-827-0482
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Fax |
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Provider Business Mailing Address
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Address Line | 8324 CRESCENT AVE
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City | BUENA PARK
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State | CA
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Zip | 90620-4024
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Country | US
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Telephone | 714-827-0482
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JEFFERSON AQUINO BAUTISTA
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Credential | N.P.
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Telephone | 714-827-0482
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | 198205266
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number | 198205266
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 198205266
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License Number State | CA
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