Provider Demographics
NPI:1194780551
Name:CAMELOT HOME HEALTH AGENCY, INC.
Entity type:Organization
Organization Name:CAMELOT HOME HEALTH AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/COO
Authorized Official - Prefix:MS
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-363-5193
Mailing Address - Street 1:17715 CHATSWORTH AVENUE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-3285
Mailing Address - Country:US
Mailing Address - Phone:818-363-5200
Mailing Address - Fax:866-387-8690
Practice Address - Street 1:17715 CHATSWORTH AVENUE
Practice Address - Street 2:SUITE 202
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-3285
Practice Address - Country:US
Practice Address - Phone:818-363-5200
Practice Address - Fax:866-387-8690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980001432251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA08204FMedicaid
CAHHA08204FMedicaid
058024Medicare Oscar/Certification