Healthcare Provider Details

I. General information

NPI: 1073483715
Provider Name (Legal Business Name): EDUARDO CAMPOS-HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2025
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W JEFFERSON BLVD STE 100
SOUTH BEND IN
46601-1993
US

IV. Provider business mailing address

2602 SUMMIT RIDGE DR
SOUTH BEND IN
46628-3453
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-2600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number05016233A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: