Healthcare Provider Details

I. General information

NPI: 1275988552
Provider Name (Legal Business Name): ODIS CAMPBELL L.P.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1744 PAYNE AVE
CLEVELAND OH
44114-2910
US

IV. Provider business mailing address

1744 PAYNE AVE
CLEVELAND OH
44114-2910
US

V. Phone/Fax

Practice location:
  • Phone: 216-623-6555
  • Fax: 216-623-6539
Mailing address:
  • Phone: 216-623-6555
  • Fax: 216-623-6539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN-072247
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: