Provider Demographics
NPI:1366124984
Name:CAMACHO VELANDIA, JUAN CAMILO (REGISTER DIETITIAN)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CAMILO
Last Name:CAMACHO VELANDIA
Suffix:
Gender:M
Credentials:REGISTER DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-268-4200
Mailing Address - Fax:321-268-1386
Practice Address - Street 1:490 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2871
Practice Address - Country:US
Practice Address - Phone:321-268-4200
Practice Address - Fax:321-268-1386
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10955133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRI498OtherPTAN HF