Healthcare Provider Details

I. General information

NPI: 1871850271
Provider Name (Legal Business Name): MR. RENE CAMACHO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 DALLAS ST
SAN ANTONIO TX
78205-1201
US

IV. Provider business mailing address

111 DALLAS ST
SAN ANTONIO TX
78205-1201
US

V. Phone/Fax

Practice location:
  • Phone: 210-297-8195
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number1171908
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: