Healthcare Provider Details

I. General information

NPI: 1558772541
Provider Name (Legal Business Name): CAMERON THERAPIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 PARKLAND DR
CLOVIS NM
88101-4474
US

IV. Provider business mailing address

501 MONTICELLO PARKWAY DR
PORTALES NM
88130-8200
US

V. Phone/Fax

Practice location:
  • Phone: 806-928-2436
  • Fax:
Mailing address:
  • Phone: 806-928-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number3292
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1525
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5171
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5169
License Number StateNM

VIII. Authorized Official

Name: MR. RUSSELL W CAMERON
Title or Position: OWNER/SECRETARY
Credential: MPT
Phone: 806-928-2436