MEDICARE: LAKEITHA CAMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156F00000X	Technician/Technologist		TX

General Provider Information

NPI Number	:	1578837126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEITHA CAMP

Provider Business Mailing Address
First Line	:	4521 MALLOW OAK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2754
Country	:	US
Telephone Number	:	469-531-3531
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 E SEMINARY DR # B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-2830
Country	:	US
Telephone Number	:	817-922-9619
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/29/2012
Last Update Date	:	03/09/2012

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Directions to “ LAKEITHA CAMP ” Practice Location

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