Healthcare Provider Details

I. General information

NPI: 1447398078
Provider Name (Legal Business Name): ROCHE KEEGAN CAMPBELL CSTFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 TURKEY LAKE RD
ORLANDO FL
32819-8001
US

IV. Provider business mailing address

PO BOX 691418
ORLANDO FL
32869-1418
US

V. Phone/Fax

Practice location:
  • Phone: 407-810-7968
  • Fax: 407-240-7681
Mailing address:
  • Phone: 407-810-7968
  • Fax: 407-240-7681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: