Healthcare Provider Details

I. General information

NPI: 1366099822
Provider Name (Legal Business Name): ADRIANA VILLA CAMACHO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5715 S BROADWAY
LOS ANGELES CA
90037-4131
US

IV. Provider business mailing address

5715 S BROADWAY
LOS ANGELES CA
90037-4131
US

V. Phone/Fax

Practice location:
  • Phone: 323-948-0444
  • Fax: 323-948-0444
Mailing address:
  • Phone: 323-948-0444
  • Fax: 323-948-0444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: