Healthcare Provider Details

I. General information

NPI: 1548010572
Provider Name (Legal Business Name): TARA S CAMPBELL RN, BSN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 MARSH DEER PL
SURFSIDE BEACH SC
29575-6204
US

IV. Provider business mailing address

PO BOX 14281
MYRTLE BEACH SC
29587-4281
US

V. Phone/Fax

Practice location:
  • Phone: 910-632-0325
  • Fax:
Mailing address:
  • Phone: 910-632-0325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number205108
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number205108
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number205108
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number205108
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number205108
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number205108
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number205108
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: