Basic Information
| Provider Information | |||||||||
| NPI: | 1124533492 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMARENA HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CAMARENA HEALTH MADERA SOUTH HIGH SCHOOL: SBHC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 299 | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936390299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596644000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 705 W PECAN AVE | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936376254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596644000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2017 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTINEZ | ||||||||
| AuthorizedOfficialFirstName: | LUZVINDA | ||||||||
| AuthorizedOfficialMiddleName: | GABRIELA | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5596644000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAMARENA HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.