Healthcare Provider Details

I. General information

NPI: 1366453490
Provider Name (Legal Business Name): MICHAEL C CAMPBELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 EAST BROAD ST
MONTICELLO MS
39654
US

IV. Provider business mailing address

PO BOX 1493
MONTICELLO MS
39654
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-0422
  • Fax: 601-587-0423
Mailing address:
  • Phone: 601-587-0422
  • Fax: 601-587-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number039031216
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number06711 11.1
License Number StateMS

VIII. Authorized Official

Name: MICHAEL CHARLES CAMPBELL
Title or Position: OWNER
Credential: CRT
Phone: 601-587-0422