Basic Information
Provider Information | |||||||||
NPI: | 1679631907 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLINICAS DEL CAMINO REAL INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLINICAS DEL CAMINO REAL, INC., VENTURA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 SOUTH WELLS ROAD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930041302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056591740 | ||||||||
FaxNumber: | 8056599959 | ||||||||
Practice Location | |||||||||
Address1: | 200 S WELLS RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930041302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056476322 | ||||||||
FaxNumber: | 8056477164 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2006 | ||||||||
LastUpdateDate: | 06/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BENHARASH | ||||||||
AuthorizedOfficialFirstName: | FARHAD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8056591740 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 050000116 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | FHC03908F | 05 | CA |   | MEDICAID | 014657 | 01 | CA | HEALTHY FAMILIES ACCESS D | OTHER | HAP03908F | 01 | CA | HEALTH ACCESS PROGRAM FAM | OTHER | W3731 | 01 | CA | MEDICARE NHIC | OTHER | BCP03908F | 01 | CA | EDS CDP EVERY WOMAN COUNT | OTHER | 201251 | 01 | CA | DELTA DENTAL | OTHER | G9088402 | 01 | CA | HEALTHY FAMILIES DELTA DE | OTHER | ZZZ06124Z | 01 | CA | BLUE SHIELD | OTHER |