Provider Demographics
NPI:1932310646
Name:CAMELOT SENIOR LIVING, INC.
Entity Type:Organization
Organization Name:CAMELOT SENIOR LIVING, INC.
Other - Org Name:CAMELOT CARE HOME 3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:EMERSON
Authorized Official - Last Name:DAHLQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-803-1955
Mailing Address - Street 1:8716 MILO CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1817
Mailing Address - Country:US
Mailing Address - Phone:916-803-1955
Mailing Address - Fax:916-685-6343
Practice Address - Street 1:8604 BANFF VISTA DR
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1708
Practice Address - Country:US
Practice Address - Phone:916-803-1955
Practice Address - Fax:916-685-6343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARCF00016FMedicaid