Provider Demographics
NPI:1861801573
Name:CAMELOT RESIDENTIAL HOMES, INC.
Entity type:Organization
Organization Name:CAMELOT RESIDENTIAL HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:AQUINO
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:714-827-0482
Mailing Address - Street 1:8324 CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4024
Mailing Address - Country:US
Mailing Address - Phone:714-827-0482
Mailing Address - Fax:
Practice Address - Street 1:8324 CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-4024
Practice Address - Country:US
Practice Address - Phone:714-827-0482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1982052663104A0625X, 3104A0630X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances