Healthcare Provider Details

I. General information

NPI: 1154415180
Provider Name (Legal Business Name): ILEANA CAMACHO LND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SARDINERA BEACH BUILDING ROAD 693 SUITE 11 URB. COSTA DE ORO
DORADO PR
00646
US

IV. Provider business mailing address

425 ROAD 693 PMB 179
DORADO PR
00646
US

V. Phone/Fax

Practice location:
  • Phone: 787-796-0959
  • Fax: 787-796-0959
Mailing address:
  • Phone: 787-796-0959
  • Fax: 787-796-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number806
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number806
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: