Healthcare Provider Details

I. General information

NPI: 1306538616
Provider Name (Legal Business Name): CHRISTOPHER CAMACHO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 WALLACE RD
AMES IA
50011-4008
US

IV. Provider business mailing address

8510 163RD ST
TINLEY PARK IL
60487-1118
US

V. Phone/Fax

Practice location:
  • Phone: 515-294-8718
  • Fax:
Mailing address:
  • Phone: 773-302-3460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: