Provider Demographics
NPI:1326215625
Name:CAMELOT REALTY LLC
Entity Type:Organization
Organization Name:CAMELOT REALTY LLC
Other - Org Name:CAMELOT CHATEAU
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-489-0857
Mailing Address - Street 1:3600 OAK MANOR LN
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-1212
Mailing Address - Country:US
Mailing Address - Phone:727-489-0857
Mailing Address - Fax:727-489-3334
Practice Address - Street 1:1831 SE LAKE WEIR AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5412
Practice Address - Country:US
Practice Address - Phone:352-629-6077
Practice Address - Fax:352-629-3792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5429310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14396601Medicaid