Basic Information
| Provider Information | |||||||||
| NPI: | 1639171861 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMELOT MANOR NURSING CARE FACILITY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 SUNSET ST | ||||||||
| Address2: | PO BOX 448 | ||||||||
| City: | GRANITE FALLS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283962387 | ||||||||
| FaxNumber: | 8283969578 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 SUNSET ST | ||||||||
| Address2: | |||||||||
| City: | GRANITE FALLS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286301770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283962387 | ||||||||
| FaxNumber: | 8283969578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 07/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | GATES | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 8283962387 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | NHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0380 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3406330 | 05 | NC | MEDICAID | 3405246 | 05 | NC | MEDICAID |