Provider Demographics
NPI:1104209105
Name:DR RENE GONZALES CAMACHO PA
Entity Type:Organization
Organization Name:DR RENE GONZALES CAMACHO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-717-8181
Mailing Address - Street 1:2030 S OCEAN DR
Mailing Address - Street 2:SUITE 2221
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-6649
Mailing Address - Country:US
Mailing Address - Phone:305-717-8181
Mailing Address - Fax:
Practice Address - Street 1:2030 S OCEAN DR
Practice Address - Street 2:SUITE 2221
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-6649
Practice Address - Country:US
Practice Address - Phone:305-717-8181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty