MEDICARE: MRS. LAURA MAHALA CAMPBELL P.T

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	225100000X	Physical Therapist	R1369	MO

General Provider Information

NPI Number	:	1598193823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA MAHALA CAMPBELL P.T

Provider Business Mailing Address
First Line	:	205 OLD HIGHWAY 40
Second Line	:
City	:	BATES CITY
State	:	MO
Zip	:	64011-8229
Country	:	US
Telephone Number	:	816-419-5519
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 OLD HIGHWAY 40
Second Line	:
City	:	BATES CITY
State	:	MO
Zip	:	64011-8229
Country	:	US
Telephone Number	:	816-419-5519
Fax Number	:

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

Provider Enumeration Date	:	10/23/2013
Last Update Date	:	10/23/2013

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