Provider Demographics
NPI:1700230976
Name:CAMELOT CARE CENTERS, LLC.
Entity Type:Organization
Organization Name:CAMELOT CARE CENTERS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATE EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-773-1988
Mailing Address - Street 1:333 W PIERCE RD STE 175
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-3120
Mailing Address - Country:US
Mailing Address - Phone:847-993-9894
Mailing Address - Fax:847-543-4534
Practice Address - Street 1:34121 NORTH ROUTE 45
Practice Address - Street 2:SUITE 207
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030
Practice Address - Country:US
Practice Address - Phone:847-993-9894
Practice Address - Fax:847-543-4534
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAYS HEALTH AND COMMUNITY SUPPORT, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-14
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05-IPI-141Medicaid