MEDICARE: MR. RICHARD CLIVE CAMPBELL

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	PT18317	FL

General Provider Information

NPI Number	:	1669699971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD CLIVE CAMPBELL

Provider Business Mailing Address
First Line	:	2331 N STATE ROAD 7
Second Line	:	STE. 102
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33313-3748
Country	:	US
Telephone Number	:	954-895-4832
Fax Number	:

Provider Business Practice Location Address
First Line	:	2331 N STATE ROAD 7
Second Line	:	STE. 102
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33313-3748
Country	:	US
Telephone Number	:	954-895-4832
Fax Number	:

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

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/09/2007

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