Provider Demographics
NPI:1447219738
Name:CAMILLUS HOUSE, INC.
Entity Type:Organization
Organization Name:CAMILLUS HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADVANCEMENT & OUTCOMES
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-374-1065
Mailing Address - Street 1:1603 NW 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1415
Mailing Address - Country:US
Mailing Address - Phone:305-374-1065
Mailing Address - Fax:305-533-2917
Practice Address - Street 1:1603 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136
Practice Address - Country:US
Practice Address - Phone:305-374-1065
Practice Address - Fax:305-533-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
FL1113AD286202324500000X
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1447219738Medicaid