=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861957789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID MICHAEL CAMPBELL DSOM, LAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2019
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 E COEUR D ALENE AVE UNIT 5
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-2873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-643-2846
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 E COEUR D ALENE AVE UNIT 5
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-2873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-643-2490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC61172209
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC190542
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | ACU-436
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------