Healthcare Provider Details

I. General information

NPI: 1417093840
Provider Name (Legal Business Name): RODRIGO CAMACHO PSYCH TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 E PALMDALE BLVD
PALMDALE CA
93550-4930
US

IV. Provider business mailing address

34230 90TH ST EAST
LITLLE ROCK CA
93543
US

V. Phone/Fax

Practice location:
  • Phone: 661-947-3333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT27341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: