MEDICARE: FABIO CAMARENA JR. SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	5280	NM

General Provider Information

NPI Number	:	1629318795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FABIO CAMARENA JR. SLP

Provider Business Mailing Address
First Line	:	301 PERKINS DR
Second Line	:	STE B
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3248
Country	:	US
Telephone Number	:	575-526-6682
Fax Number	:	575-652-4104

Provider Business Practice Location Address
First Line	:	1080 MED PARK DR
Second Line	:	STE A
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3226
Country	:	US
Telephone Number	:	575-647-3773
Fax Number	:	575-647-3777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2013
Last Update Date	:	02/26/2013

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