Basic Information
| Provider Information | |||||||||
| NPI: | 1972761013 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMELOT OF KANSAS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKESIDE ACADEMY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4207 E HIGHWAY 290 | ||||||||
| Address2: | |||||||||
| City: | DRIPPING SPRINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786204206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128589900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24401 W MACARTHUR RD | ||||||||
| Address2: | |||||||||
| City: | GODDARD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670528713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167942760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2008 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARCOURT | ||||||||
| AuthorizedOfficialFirstName: | GRAYSON | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5128589900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.