MEDICARE: CAMILLE RESIDENCES

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1538319835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMILLE RESIDENCES

Provider Business Mailing Address
First Line	:	7632 BECKWOOD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-6052
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4904 CAMILLE CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-1704
Country	:	US
Telephone Number	:	817-703-5012
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. CHRISTI OLAOSEBIKAN
Credential	:
Telephone Number	:	817-703-5012

Provider Enumeration Date	:	09/23/2008
Last Update Date	:	09/23/2008

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