Provider Demographics
NPI:1952771248
Name:CAMACHO, RICKY
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 1/2 N VIA VAL VERDE
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3038
Mailing Address - Country:US
Mailing Address - Phone:323-887-7404
Mailing Address - Fax:
Practice Address - Street 1:402 1/2 N VIA VAL VERDE
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3038
Practice Address - Country:US
Practice Address - Phone:323-887-7404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator