Provider Demographics
NPI:1700149051
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:MRS
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 1:2396 W NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3111
Mailing Address - Country:US
Mailing Address - Phone:309-676-6305
Mailing Address - Fax:309-676-6519
Practice Address - Street 1:2396 W NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-3111
Practice Address - Country:US
Practice Address - Phone:309-676-6305
Practice Address - Fax:309-676-6519
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAYS HEALTH AND COMMUNITY SUPPORT, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-21
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05-IPI-141Medicaid