Healthcare Provider Details

I. General information

NPI: 1427415306
Provider Name (Legal Business Name): HILARY B CAMPBELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BOND AVE
EAST SAINT LOUIS IL
62207-2326
US

IV. Provider business mailing address

PO BOX 185
EAST SAINT LOUIS IL
62202-0185
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-5458
  • Fax: 618-332-5256
Mailing address:
  • Phone: 618-332-5458
  • Fax: 618-332-5256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2015004097
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: