Provider Demographics
NPI:1720362056
Name:CLINICAS DEL CAMINO REAL INC
Entity Type:Organization
Organization Name:CLINICAS DEL CAMINO REAL INC
Other - Org Name:CLINICAS DEL CAMINO REAL, INC. SIMI VALLEY MADERA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFCIER
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BENHARASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-659-1740
Mailing Address - Street 1:200 S WELLS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1377
Mailing Address - Country:US
Mailing Address - Phone:805-659-1740
Mailing Address - Fax:805-659-9959
Practice Address - Street 1:1424 MADERA RD
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3000
Practice Address - Country:US
Practice Address - Phone:805-522-5722
Practice Address - Fax:805-672-0107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001837261QC1500X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720362056Medicaid
CAW3731Medicare PIN
CA551159Medicare Oscar/Certification