Provider Demographics
NPI:1740510338
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:R
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-773-1985
Mailing Address - Street 1:333 W PIERCE RD STE 175
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-3120
Mailing Address - Country:US
Mailing Address - Phone:217-585-9185
Mailing Address - Fax:217-585-8522
Practice Address - Street 1:2144 S MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4502
Practice Address - Country:US
Practice Address - Phone:217-585-9185
Practice Address - Fax:217-585-8522
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAYS HEALTH AND SUPPORT SERVICES, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-05
Last Update Date:2021-10-18
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