Healthcare Provider Details

I. General information

NPI: 1215306527
Provider Name (Legal Business Name): AMANDA CAMPBELL D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W EAU GALLIE BLVD SUITE 104
MELBOURNE FL
32935-4149
US

IV. Provider business mailing address

1600 W EAU GALLIE BLVD. SUITE 104
MELBOURNE FL
32935
US

V. Phone/Fax

Practice location:
  • Phone: 321-622-4447
  • Fax:
Mailing address:
  • Phone: 321-622-4447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH11607
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: