Provider Demographics
NPI:1124390018
Name:CAMHOL, MELBOURNE GENEVA NICODAM
Entity Type:Individual
Prefix:MISS
First Name:MELBOURNE GENEVA
Middle Name:NICODAM
Last Name:CAMHOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49820 CALLE QUINTERRA
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-7331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1580 SAWGRS CORP PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2859
Practice Address - Country:US
Practice Address - Phone:954-739-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.018752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist