Healthcare Provider Details

I. General information

NPI: 1770492019
Provider Name (Legal Business Name): CAMILLE THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1667 N MOUNTAIN AVE
UPLAND CA
91784-1781
US

IV. Provider business mailing address

520 N CENTRAL AVE APT 1107
UPLAND CA
91786-7692
US

V. Phone/Fax

Practice location:
  • Phone: 909-917-4569
  • Fax:
Mailing address:
  • Phone: 909-917-4569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: