MEDICARE: JON WILLIAM CAMPO L.P.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	250970-1	NY

General Provider Information

NPI Number	:	1720302854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON WILLIAM CAMPO L.P.N.

Provider Business Mailing Address
First Line	:	332 LAKE SHORE DR
Second Line	:
City	:	HILTON
State	:	NY
Zip	:	14468-9559
Country	:	US
Telephone Number	:	585-392-0168
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 STATE ST
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14614-1353
Country	:	US
Telephone Number	:	585-454-3550
Fax Number	:	585-232-4231

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2010
Last Update Date	:	03/18/2010

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