Provider Demographics
NPI:1710102330
Name:CAMINO REAL COMMUNITY MHMR CENTER
Entity Type:Organization
Organization Name:CAMINO REAL COMMUNITY MHMR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LOREN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-357-0369
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-0725
Mailing Address - Country:US
Mailing Address - Phone:210-357-0369
Mailing Address - Fax:210-357-0458
Practice Address - Street 1:19965 FM 3175 NORTH
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052
Practice Address - Country:US
Practice Address - Phone:210-357-0369
Practice Address - Fax:210-357-0458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services