Healthcare Provider Details

I. General information

NPI: 1174286801
Provider Name (Legal Business Name): MRS. JIA LI CAMACHO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 CORONADO CENTER DR SUITE 200
HENDERSON NV
89052-3977
US

IV. Provider business mailing address

7108 SOUTH KANNER HWY
STUART FL
34997-7462
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax: 772-675-9100
Mailing address:
  • Phone: 855-832-6727
  • Fax: 772-675-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA1094
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: