Healthcare Provider Details

I. General information

NPI: 1861691115
Provider Name (Legal Business Name): CULLEN LEE CAMPBELL L.S.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 9TH ST STE 260
LUBBOCK TX
79415-5305
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3545
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-8185
  • Fax: 806-792-9180
Mailing address:
  • Phone: 806-761-0333
  • Fax: 806-792-9180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License NumberSA00109
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00109
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: