Basic Information
| Provider Information | |||||||||
| NPI: | 1740375062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMACHO VALJI | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | ELLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAMACHO | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | ELLA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6070 AVENIDA ENCINAS | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604440102 | ||||||||
| FaxNumber: | 7606883131 | ||||||||
| Practice Location | |||||||||
| Address1: | 6070 AVENIDA ENCINAS | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604440102 | ||||||||
| FaxNumber: | 7606883131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT23007 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT23007 | 01 | CA | PT LICENSE | OTHER |