Provider Demographics
NPI:1417167644
Name:CAMELOT HEALTH CARE CORPORATION
Entity Type:Organization
Organization Name:CAMELOT HEALTH CARE CORPORATION
Other - Org Name:CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTING
Authorized Official - Prefix:MR
Authorized Official - First Name:MARINO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-264-1556
Mailing Address - Street 1:310 E PIONEER PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-4940
Mailing Address - Country:US
Mailing Address - Phone:972-264-1556
Mailing Address - Fax:972-264-1565
Practice Address - Street 1:310 E PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4940
Practice Address - Country:US
Practice Address - Phone:972-264-1556
Practice Address - Fax:972-264-1565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1002459261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy