Healthcare Provider Details

I. General information

NPI: 1750822771
Provider Name (Legal Business Name): BILLY RAY CAMPBELL III CPED, CFO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E BROADWAY STE 1400
LOUISVILLE KY
40202-3700
US

IV. Provider business mailing address

3401 IMPERATOR LN UNIT 102
LOUISVILLE KY
40245-7707
US

V. Phone/Fax

Practice location:
  • Phone: 502-629-8640
  • Fax: 502-629-5527
Mailing address:
  • Phone: 502-593-6119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberCPED3595
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberCFO04010
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: