Provider Demographics
NPI:1407378177
Name:CAMACHO, NICOLE (MAT # 14948)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:MAT # 14948
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1073
Mailing Address - Street 2:
Mailing Address - City:CAPTAIN COOK
Mailing Address - State:HI
Mailing Address - Zip Code:96704-1073
Mailing Address - Country:US
Mailing Address - Phone:808-937-0213
Mailing Address - Fax:
Practice Address - Street 1:75-5759 KUAKINI HWY STE 103E
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1726
Practice Address - Country:US
Practice Address - Phone:808-937-0213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14948225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI$$$$$$$$$Medicaid