Provider Demographics
NPI:1134362106
Name:CAMELLIA HOSPICE OF THE GULF COAST, LLC
Entity type:Organization
Organization Name:CAMELLIA HOSPICE OF THE GULF COAST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-239-6500
Mailing Address - Street 1:6688 N CENTRAL EXPY STE 1300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-3950
Mailing Address - Country:US
Mailing Address - Phone:214-239-6500
Mailing Address - Fax:214-239-6581
Practice Address - Street 1:13155 SHRINERS BLVD STE D
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-8745
Practice Address - Country:US
Practice Address - Phone:228-374-4434
Practice Address - Fax:228-436-3679
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENHABIT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-07
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04233255Medicaid
MS04233255Medicaid