Provider Demographics
NPI:1699047548
Name:CAMELOT OF STATEN ISLAND INC.
Entity type:Organization
Organization Name:CAMELOT OF STATEN ISLAND INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:NASTA
Authorized Official - Suffix:
Authorized Official - Credentials:MPA, CASAC
Authorized Official - Phone:718-981-8117
Mailing Address - Street 1:17515 ROCKAWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-5503
Mailing Address - Country:US
Mailing Address - Phone:718-632-3275
Mailing Address - Fax:718-632-7952
Practice Address - Street 1:17515 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-5503
Practice Address - Country:US
Practice Address - Phone:718-632-3275
Practice Address - Fax:718-632-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center