Healthcare Provider Details

I. General information

NPI: 1871161885
Provider Name (Legal Business Name): CAMINO RENAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 EXECUTIVE SQ STE 450
LA JOLLA CA
92037-8411
US

IV. Provider business mailing address

4225 EXECUTIVE SQ STE 450
LA JOLLA CA
92037-8411
US

V. Phone/Fax

Practice location:
  • Phone: 858-810-8000
  • Fax:
Mailing address:
  • Phone: 858-810-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GLENN DAVIS
Title or Position: PRESIDENT
Credential:
Phone: 949-246-8581