=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952642068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELPLEX OF PRESCOTT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2013
-----------------------------------------------------
Last Update Date | 03/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1672 OAKLAWN DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-445-5339
-----------------------------------------------------
Fax | 928-445-3644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1672 OAKLAWN DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-445-5339
-----------------------------------------------------
Fax | 928-445-3644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DOUGLAS J CAMPBELL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 928-445-5339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 28543
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------