MEDICARE: CAMPBELL MEDICAL CARE, LLC

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	363LG0600X	Gerontology Nurse Practitioner	005055	CT

General Provider Information

NPI Number	:	1891247805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMPBELL MEDICAL CARE, LLC

Provider Business Mailing Address
First Line	:	22 PARKWOOD DR
Second Line	:
City	:	WINDSOR
State	:	CT
Zip	:	06095-3142
Country	:	US
Telephone Number	:	860-810-2943
Fax Number	:	860-687-0887

Provider Business Practice Location Address
First Line	:	22 PARKWOOD DR
Second Line	:
City	:	WINDSOR
State	:	CT
Zip	:	06095-3142
Country	:	US
Telephone Number	:	860-810-2943
Fax Number	:	860-687-0887

Authorized Official
Title or Position	:	OWNER
Name	:	ANNETTA R TROCHE
Credential	:	APRN
Telephone Number	:	860-810-2943

Provider Enumeration Date	:	10/26/2016
Last Update Date	:	10/26/2016

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