Provider Demographics
NPI:1154639292
Name:BACLAGAN, CAMILLE C (N/A)
Entity Type:Individual
Prefix:MRS
First Name:CAMILLE
Middle Name:C
Last Name:BACLAGAN
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1992
Mailing Address - Country:US
Mailing Address - Phone:213-934-8332
Mailing Address - Fax:
Practice Address - Street 1:510 S VERMONT AVE FL 18
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1912
Practice Address - Country:US
Practice Address - Phone:562-651-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA225400000XOtherREHABILITATION PRACTITIONER