Basic Information
Provider Information | |||||||||
NPI: | 1093933194 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLINICAS DEL CAMINO REAL INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLINICAS DEL CAMINO REAL, INC., KAREN R BURNHAM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 S WELLS RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930041302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056591740 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1100 W GONZALES RD | ||||||||
Address2: |   | ||||||||
City: | OXNARD | ||||||||
State: | CA | ||||||||
PostalCode: | 930363336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8059880053 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2007 | ||||||||
LastUpdateDate: | 06/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BENHARASH | ||||||||
AuthorizedOfficialFirstName: | FARHAD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8056591740 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 550000025 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | FHC71077F | 05 | CA |   | MEDICAID | BCP71077F | 01 | CA | EDS CDP EVERY WOMAN COUNT | OTHER | HAP71077F | 01 | CA | HEALTH ACCESS PROGRAM FAM | OTHER |