Basic Information
| Provider Information | |||||||||
| NPI: | 1194274811 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMINO HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30300 CAMINO CAPISTRANO | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492402030 | ||||||||
| FaxNumber: | 9494297627 | ||||||||
| Practice Location | |||||||||
| Address1: | 22481 ASPAN ST STE A | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926301630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492402030 | ||||||||
| FaxNumber: | 9494297627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2016 | ||||||||
| LastUpdateDate: | 09/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | JORGENSEN | ||||||||
| AuthorizedOfficialFirstName: | GARTH | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCIAL SERVICES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9492402030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAMINO HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 060000060 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.