Healthcare Provider Details

I. General information

NPI: 1154411262
Provider Name (Legal Business Name): CAMINO REAL COMMUNITY MHMR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19965 FM 3175
LYTLE TX
78052-3481
US

IV. Provider business mailing address

PO BOX 725
LYTLE TX
78052-0725
US

V. Phone/Fax

Practice location:
  • Phone: 210-357-0300
  • Fax: 855-240-1374
Mailing address:
  • Phone: 210-357-0300
  • Fax: 855-240-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREA CORONA
Title or Position: REIMBURSEMENT/CREDENTIALING SPEC
Credential:
Phone: 210-357-0369