Provider Demographics
NPI:1831487032
Name:LE CAMELOT LLC
Entity Type:Organization
Organization Name:LE CAMELOT LLC
Other - Org Name:LE CAMELOT WELLNESS SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LMT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:SOULE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:813-774-4475
Mailing Address - Street 1:19923 JODI DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5005
Mailing Address - Country:US
Mailing Address - Phone:813-774-4475
Mailing Address - Fax:813-435-2001
Practice Address - Street 1:19923 JODI DR
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-5005
Practice Address - Country:US
Practice Address - Phone:813-774-4475
Practice Address - Fax:813-435-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA005943225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1285961037OtherINDIVIDUAL NPI
FL9566677OtherAETNA