Provider Demographics
NPI:1134644511
Name:CAMACHO, EDGAR
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3933 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3523
Mailing Address - Country:US
Mailing Address - Phone:909-573-7537
Mailing Address - Fax:
Practice Address - Street 1:10000 COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3508
Practice Address - Country:US
Practice Address - Phone:909-573-7537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA114430104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health