Basic Information
| Provider Information | |||||||||
| NPI: | 1184074650 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMELOT REALTY, LLC | ||||||||
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| OtherOrganizationName: | JACKSON LANE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9901 LINN STATION RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402233808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023942100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1909 JACKSON LANE | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138584550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2016 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | PANK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PARALEGAL | ||||||||
| AuthorizedOfficialTelephone: | 5024202666 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
No ID Information.