Provider Demographics
NPI:1689943078
Name:CAMELOT BROOKSIDE LLC
Entity Type:Organization
Organization Name:CAMELOT BROOKSIDE LLC
Other - Org Name:CAMELOT BROOKSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-445-6470
Mailing Address - Street 1:4333 SHREVEPORT HWY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-3828
Mailing Address - Country:US
Mailing Address - Phone:318-445-6470
Mailing Address - Fax:
Practice Address - Street 1:3330 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-3269
Practice Address - Country:US
Practice Address - Phone:337-824-2466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility