Healthcare Provider Details

I. General information

NPI: 1629267307
Provider Name (Legal Business Name): KELVIN D CAMPBELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-9149
  • Fax: 505-272-9843
Mailing address:
  • Phone: 505-272-9149
  • Fax: 505-272-9843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: