Basic Information
| Provider Information | |||||||||
| NPI: | 1124390018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMHOL | ||||||||
| FirstName: | MELBOURNE GENEVA | ||||||||
| MiddleName: | NICODAM | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 49820 CALLE QUINTERRA | ||||||||
| Address2: | |||||||||
| City: | COACHELLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922367331 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1580 SAWGRS CORP PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547394247 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2012 | ||||||||
| LastUpdateDate: | 02/07/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070.018752 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.