Provider Demographics
NPI:1164978656
Name:CAMELLIA HOUSE LLC
Entity Type:Organization
Organization Name:CAMELLIA HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:EPHAIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-227-1105
Mailing Address - Street 1:8027 CAMELLIA RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-3416
Mailing Address - Country:US
Mailing Address - Phone:757-227-1105
Mailing Address - Fax:
Practice Address - Street 1:8027 CAMELLIA RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-3416
Practice Address - Country:US
Practice Address - Phone:757-227-1105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2991320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities