Basic Information
| Provider Information | |||||||||
| NPI: | 1952555823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMACHO | ||||||||
| FirstName: | MARY GRAYLE | ||||||||
| MiddleName: | JALALAIN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28022 MARGUERITE PKWY | ||||||||
| Address2: | APT. C | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926923611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144231315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 ODYSSEY | ||||||||
| Address2: | #165 | ||||||||
| City: | IRVINE, | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497272192 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2008 | ||||||||
| LastUpdateDate: | 01/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070016394 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 37616 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.