Healthcare Provider Details

I. General information

NPI: 1356609655
Provider Name (Legal Business Name): TIMOTHY PERROW CAMPBELL LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NAMBE ST
SANTA FE NM
87505-3817
US

IV. Provider business mailing address

201 NAMBE ST
SANTA FE NM
87505-3817
US

V. Phone/Fax

Practice location:
  • Phone: 505-795-0467
  • Fax:
Mailing address:
  • Phone: 505-795-0467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6487
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: