Healthcare Provider Details

I. General information

NPI: 1619967148
Provider Name (Legal Business Name): GLENN MARVIN CAMPBELL OTRIL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE 3RD MDG
ELMENDORF AFB AK
99506-3702
US

IV. Provider business mailing address

7402 METZGER AVE UNIT A
ELMENDORF AFB AK
99506-2021
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-1700
  • Fax:
Mailing address:
  • Phone: 907-333-8281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTE000241L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC002460L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: