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General NPI Number Information
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NPI Number | 1164615845
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Entity Type | Individual
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Provider Name | ETHAN TROY CAMPBELL A.T.C., L.A.T
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Gender | Male
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Dates
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Enumeration Date | 08/25/2007
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Last Update Date | 08/25/2007
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Provider Practice Location Address
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Address Line | 601 PATE ORR RD N
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City | KELLER
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State | TX
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Zip | 76248-4209
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Country | US
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Telephone | 817-744-1465
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Fax | 817-744-1503
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Provider Business Mailing Address
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Address Line | 601 PATE ORR RD N
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City | KELLER
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State | TX
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Zip | 76248-4209
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Country | US
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Telephone | 817-744-1465
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Fax | 817-744-1503
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT2055
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License Number State | TX
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