Provider Demographics
NPI:1942795075
Name:CAMACHO, SARA
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:
Last Name:CAMACHO
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 1:3504 BERYL LN
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-1702
Mailing Address - Country:US
Mailing Address - Phone:915-599-7058
Mailing Address - Fax:
Practice Address - Street 1:3504 BERYL LN
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904-1702
Practice Address - Country:US
Practice Address - Phone:915-599-7058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$Medicaid