Healthcare Provider Details

I. General information

NPI: 1407192297
Provider Name (Legal Business Name): JOHN CAMPOS LVN, LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2012
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 S HAM LN
LODI CA
95242-3059
US

IV. Provider business mailing address

10420 CARNEGIE CT
STOCKTON CA
95209-3752
US

V. Phone/Fax

Practice location:
  • Phone: 209-224-8940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberVN260740
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN260740
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT36061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: