Healthcare Provider Details

I. General information

NPI: 1184246126
Provider Name (Legal Business Name): CAMILO ERNESTO GUEVARA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 BILL OWENS PKWY
LONGVIEW TX
75604-6243
US

IV. Provider business mailing address

402 N 7TH ST
LONGVIEW TX
75601-6704
US

V. Phone/Fax

Practice location:
  • Phone: 903-212-7808
  • Fax: 903-212-7121
Mailing address:
  • Phone: 903-931-3242
  • Fax: 903-212-7121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number848601
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number848601
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: