Basic Information
| Provider Information | |||||||||
| NPI: | 1366560393 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMINO HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CAMINO HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 30300 CAMINO CAPISTRANO | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492402030 | ||||||||
| FaxNumber: | 9494297627 | ||||||||
| Practice Location | |||||||||
| Address1: | 30300 CAMINO CAPISTRANO | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492402030 | ||||||||
| FaxNumber: | 9494297627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DREW | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9492402030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 060000060 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | CMM70345H | 01 | CA | MEDICAL | OTHER | W14149 | 01 | CA | MEDICARE PART B | OTHER | CMM70345H | 01 | CA | CALOPTIMA | OTHER | G91459-01 | 01 | CA | DENTICAL | OTHER | CMM70345H | 01 | CA | CHDP | OTHER | EAP70345H | 01 | CA | EAPC | OTHER |