Basic Information
| Provider Information | |||||||||
| NPI: | 1871709493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMARGO | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9240 DATE ST | ||||||||
| Address2: | APT. 12-C | ||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923358724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143571981 | ||||||||
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| Practice Location | |||||||||
| Address1: | 560 S SAN JOSE AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917233144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269675103 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | X | Other Service Providers | Case Manager/Care Coordinator | 225400000X | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | TFC6365 | 05 | CA | MEDICAID |