Provider Demographics
NPI:1124507553
Name:CRUMBY, CAMEO JAMAR (ADMINISTRATOR)
Entity type:Individual
Prefix:
First Name:CAMEO
Middle Name:JAMAR
Last Name:CRUMBY
Suffix:
Gender:M
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3662 PATRICIA DR NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-5625
Mailing Address - Country:US
Mailing Address - Phone:330-329-5961
Mailing Address - Fax:
Practice Address - Street 1:3662 PATRICIA DR NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-5625
Practice Address - Country:US
Practice Address - Phone:330-329-5961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC83-0982968Medicaid