Healthcare Provider Details

I. General information

NPI: 1013488360
Provider Name (Legal Business Name): CAMACHO CHIROPRACTIC AND SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 N EUCLID ST
GRANDVIEW WA
98930-9407
US

IV. Provider business mailing address

403 N EUCLID ST
GRANDVIEW WA
98930-9407
US

V. Phone/Fax

Practice location:
  • Phone: 509-402-9020
  • Fax: 509-402-9036
Mailing address:
  • Phone: 509-402-9020
  • Fax: 509-402-9036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGELA MARIE CAMACHO
Title or Position: OFFICE MANAGER
Credential:
Phone: 509-402-9020