Provider Demographics
NPI:1154415180
Name:CAMACHO, ILEANA (LND)
Entity type:Individual
Prefix:MRS
First Name:ILEANA
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ROAD 693
Mailing Address - Street 2:PMB 179
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646
Mailing Address - Country:US
Mailing Address - Phone:787-796-0959
Mailing Address - Fax:787-796-0959
Practice Address - Street 1:SARDINERA BEACH BUILDING ROAD 693
Practice Address - Street 2:SUITE 11 URB. COSTA DE ORO
Practice Address - City:DORADO
Practice Address - State:PR
Practice Address - Zip Code:00646
Practice Address - Country:US
Practice Address - Phone:787-796-0959
Practice Address - Fax:787-796-0959
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR806133N00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRNUT 036OtherPREFFERED HEALTH PLAN
PR6460066OtherHUMANA HEALTH PLAN DE PR
PR6606607381OtherMCS CLASSICARE
PRQ-64302Medicare UPIN
PR6606607381OtherMCS CLASSICARE