=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679631907
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICAS DEL CAMINO REAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 06/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S WELLS RD SUITE 100
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93004-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-647-6322
-----------------------------------------------------
Fax | 805-647-7164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 SOUTH WELLS ROAD SUITE 200
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93004-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-659-1740
-----------------------------------------------------
Fax | 805-659-9959
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | FARHAD BENHARASH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 805-659-1740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number | 050000116
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------