Provider Demographics
NPI:1639171861
Name:CAMELOT MANOR NURSING CARE FACILITY INC
Entity Type:Organization
Organization Name:CAMELOT MANOR NURSING CARE FACILITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:828-396-2387
Mailing Address - Street 1:100 SUNSET ST
Mailing Address - Street 2:PO BOX 448
Mailing Address - City:GRANITE FALLS
Mailing Address - State:NC
Mailing Address - Zip Code:28630
Mailing Address - Country:US
Mailing Address - Phone:828-396-2387
Mailing Address - Fax:828-396-9578
Practice Address - Street 1:100 SUNSET ST
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:NC
Practice Address - Zip Code:28630-1770
Practice Address - Country:US
Practice Address - Phone:828-396-2387
Practice Address - Fax:828-396-9578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0380314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406330Medicaid
NC3405246Medicaid
NC=========OtherPVT INSURANCE
NC3406330Medicaid