Healthcare Provider Details

I. General information

NPI: 1669540555
Provider Name (Legal Business Name): RUDOLFO BRUCE CAMPOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 MCCORMICK CANYON
CLIFTON AZ
85533
US

IV. Provider business mailing address

114 MCCORMICK CANYON
CLIFTON AZ
85533
US

V. Phone/Fax

Practice location:
  • Phone: 928-865-3109
  • Fax:
Mailing address:
  • Phone: 928-865-3109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: