Healthcare Provider Details

I. General information

NPI: 1679316749
Provider Name (Legal Business Name): TONY JORDAN CAMERON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 W MOUNTAIN ST
PASADENA CA
91103-2967
US

IV. Provider business mailing address

901 ROYAL OAKS DR
MONROVIA CA
91016-3700
US

V. Phone/Fax

Practice location:
  • Phone: 323-924-9084
  • Fax:
Mailing address:
  • Phone: 626-879-7991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: