MEDICARE: CAMELOT OF VIRGINIA, 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1245426428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMELOT OF VIRGINIA, LLC

Provider Business Mailing Address
First Line	:	4207 E HIGHWAY 290
Second Line	:
City	:	DRIPPING SPRINGS
State	:	TX
Zip	:	78620-4206
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4410 CHRISTIANSBURG PIKE
Second Line	:
City	:	PILOT
State	:	VA
Zip	:	24138
Country	:	US
Telephone Number	:	540-745-3887
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS OFFICE DIRECTOR
Name	:	GRAYSON HARCOURT
Credential	:
Telephone Number	:	512-858-9900

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	09/20/2007

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