Basic Information
| Provider Information | |||||||||
| NPI: | 1720362056 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINICAS DEL CAMINO REAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CLINICAS DEL CAMINO REAL, INC. SIMI VALLEY MADERA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S WELLS RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930041377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056591740 | ||||||||
| FaxNumber: | 8056599959 | ||||||||
| Practice Location | |||||||||
| Address1: | 1424 MADERA RD | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930653000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055225722 | ||||||||
| FaxNumber: | 8056720107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENHARASH | ||||||||
| AuthorizedOfficialFirstName: | FARHAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFCIER | ||||||||
| AuthorizedOfficialTelephone: | 8056591740 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 550001837 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X | 550001837 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1720362056 | 05 | CA | MEDICAID |