Healthcare Provider Details

I. General information

NPI: 1780897207
Provider Name (Legal Business Name): JACK WARREN CAMPBELL IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NMCB 133
FPO AA
34099
US

IV. Provider business mailing address

1703 CHANCER LN
SLIDELL LA
70461-4558
US

V. Phone/Fax

Practice location:
  • Phone: 228-871-2819
  • Fax:
Mailing address:
  • Phone: 228-313-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: