Basic Information
Provider Information | |||||||||
NPI: | 1447309885 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CAMARENA HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 299 | ||||||||
Address2: |   | ||||||||
City: | MADERA | ||||||||
State: | CA | ||||||||
PostalCode: | 936390299 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5596644000 | ||||||||
FaxNumber: | 5596755625 | ||||||||
Practice Location | |||||||||
Address1: | 300 PROSPERITY BLVD | ||||||||
Address2: |   | ||||||||
City: | CHOWCHILLA | ||||||||
State: | CA | ||||||||
PostalCode: | 936108498 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5596644000 | ||||||||
FaxNumber: | 5596755625 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2007 | ||||||||
LastUpdateDate: | 07/16/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SOARES | ||||||||
AuthorizedOfficialFirstName: | PAULO | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5596644000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1223G0001X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 126800000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Assistant |   | 261QF0400X | 550000137 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | BCP71114F | 01 | CA | MEDICAL | OTHER | HAP71114F | 01 | CA | MEDICAL | OTHER | FHC71114F | 01 | CA | MEDICAL | OTHER |