Provider Demographics
NPI:1023349081
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:630-773-1985
Mailing Address - Street 1:5301 E STATE ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2901
Mailing Address - Country:US
Mailing Address - Phone:815-484-9180
Mailing Address - Fax:815-484-9183
Practice Address - Street 1:5301 E STATE ST
Practice Address - Street 2:SUITE 208
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2901
Practice Address - Country:US
Practice Address - Phone:815-484-9180
Practice Address - Fax:815-484-9183
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAYS HEALTH AND COMMUNITY SUPPORT, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-14
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05-IPI-141Medicaid