Basic Information
| Provider Information | |||||||||
| NPI: | 1174989297 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMARENA HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CAMARENA HEALTH-COUNTRY CLUB DRIVE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 299 | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936390299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596644000 | ||||||||
| FaxNumber: | 5596755625 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 COUNTRY CLUB DR STE E | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936382691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596644000 | ||||||||
| FaxNumber: | 5596755625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2016 | ||||||||
| LastUpdateDate: | 06/13/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOARES | ||||||||
| AuthorizedOfficialFirstName: | PAULO | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5596644000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAMARENA HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 040000045 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.