Provider Demographics
NPI:1912026261
Name:CAMELOT CARE CENTERS
Entity Type:Organization
Organization Name:CAMELOT CARE CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-860-5724
Mailing Address - Street 1:10304 SPOTSYLVANIA AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-8602
Mailing Address - Country:US
Mailing Address - Phone:540-710-2800
Mailing Address - Fax:540-710-6447
Practice Address - Street 1:11711 ARBOR ST STE 110
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2975
Practice Address - Country:US
Practice Address - Phone:402-392-2972
Practice Address - Fax:402-392-2978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE51069149320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========-28Medicaid
NE=========-27Medicaid