MEDICARE: CAMELOT HEALTHCARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1043889678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMELOT HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	477 N LINDBERGH BLVD STE 310
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-7856
Country	:	US
Telephone Number	:	314-631-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 GRAND CANYON DR
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-2161
Country	:	US
Telephone Number	:	573-756-8911
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JUDAH BIENSTOCK
Credential	:
Telephone Number	:	314-631-3000

Provider Enumeration Date	:	06/18/2021
Last Update Date	:	06/18/2021

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Directions to “CAMELOT HEALTHCARE, LLC ” Practice Location

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