1972301331 NPI number — LESLIE JOANNA CAMACHO MACIEL R1480640922

Table of content: LESLIE JOANNA CAMACHO MACIEL R1480640922 (NPI 1972301331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972301331 NPI number — LESLIE JOANNA CAMACHO MACIEL R1480640922

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMACHO MACIEL
Provider First Name:
LESLIE
Provider Middle Name:
JOANNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R1480640922
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972301331
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2348 RUSSELL PARK WAY APT 733
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108-1345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-794-8762
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4443 30TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92116-4288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-597-7335
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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