Basic Information
| Provider Information | |||||||||
| NPI: | 1578560462 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BHM MEDICAL FACILITIES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAMELOT NURSING & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 GRAND CANYON DR | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636402161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737568911 | ||||||||
| FaxNumber: | 5737560862 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 GRAND CANYON DR | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636402161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737568911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | GENE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5737568911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 031109 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 101456200 | 05 | MO | MEDICAID | 198617 | 01 | MO | BLUECROSS AND BLUE SHIELD | OTHER | 031109 | 01 | MO | FACILITY LICENSE NUMBER | OTHER |