=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043243009
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY ANN CAMACHO P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2590 HOLIDAY RD STE 10
-----------------------------------------------------
City | CORALVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52241-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-625-3030
-----------------------------------------------------
Fax | 319-625-3032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 ZELLER XING APT 207
-----------------------------------------------------
City | NORTH LIBERTY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52317-9468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-530-5468
-----------------------------------------------------
Fax | 319-625-3032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 03522
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------