=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184246126
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMILO ERNESTO GUEVARA RN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2020
-----------------------------------------------------
Last Update Date | 03/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 BILL OWENS PKWY
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75604-6243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-212-7808
-----------------------------------------------------
Fax | 903-212-7121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 N 7TH ST
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-6704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-931-3242
-----------------------------------------------------
Fax | 903-212-7121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Registered Nurse
-----------------------------------------------------
License Number | 848601
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WA2000X
-----------------------------------------------------
Taxonomy Name | Administrator Registered Nurse
-----------------------------------------------------
License Number | 848601
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------