=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316226681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN TAYLOR CAMPBELL COA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2011
-----------------------------------------------------
Last Update Date | 08/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 E BONITA AVE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-1926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-621-1180
-----------------------------------------------------
Fax | 909-625-7535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 E BONITA AVE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-1926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-621-1180
-----------------------------------------------------
Fax | 909-625-7535
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225000000X
-----------------------------------------------------
Taxonomy Name | Orthotic Fitter
-----------------------------------------------------
License Number | COA00174
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------