=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538549449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMINO HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2015
-----------------------------------------------------
Last Update Date | 06/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 AVENIDA VISTA HERMOSA STE 250
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-240-2030
-----------------------------------------------------
Fax | 949-429-7627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30300 CAMINO CAPISTRANO
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-240-2030
-----------------------------------------------------
Fax | 949-429-7627
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DEBRA DREW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-240-2030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | 060000060
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------