Healthcare Provider Details

I. General information

NPI: 1417202086
Provider Name (Legal Business Name): IRINA SELS CAMPBELL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 VERDOLAGA ROAD
EL PRADO NM
87529
US

IV. Provider business mailing address

PO BOX 2198
RANCHOS DE TAOS NM
87557-2198
US

V. Phone/Fax

Practice location:
  • Phone: 575-613-3133
  • Fax:
Mailing address:
  • Phone: 575-613-3133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6907
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: