Provider Demographics
NPI:1265628440
Name:CAMELOT OF VIRGINIA, LLC
Entity Type:Organization
Organization Name:CAMELOT OF VIRGINIA, LLC
Other - Org Name:RADFORD GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRAYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:HARCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-858-9900
Mailing Address - Street 1:4207 E HIGHWAY 290
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-4206
Mailing Address - Country:US
Mailing Address - Phone:512-858-9900
Mailing Address - Fax:
Practice Address - Street 1:5978 BELSPRINGS RD.
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141
Practice Address - Country:US
Practice Address - Phone:540-639-1688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness