Healthcare Provider Details

I. General information

NPI: 1215061395
Provider Name (Legal Business Name): MIGUEL A CAMACHO M.A, CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7201 N INTERSTATE AVE
PORTLAND OR
97217-5523
US

IV. Provider business mailing address

7201 N INTERSTATE AVE
PORTLAND OR
97217-5523
US

V. Phone/Fax

Practice location:
  • Phone: 503-240-3917
  • Fax:
Mailing address:
  • Phone: 503-240-3917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: