Provider Demographics
NPI:1558481119
Name:CAMELLIA GARDENS
Entity Type:Organization
Organization Name:CAMELLIA GARDENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:LAVALLE
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:919-544-0257
Mailing Address - Street 1:5010 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4425
Mailing Address - Country:US
Mailing Address - Phone:919-544-0257
Mailing Address - Fax:
Practice Address - Street 1:5010 S ALSTON AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-4425
Practice Address - Country:US
Practice Address - Phone:919-544-0257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-032-071310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility