MEDICARE: KENNETH CAMPBELL JR. LPN

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	164W00000X	Licensed Practical Nurse	PN.140772-M-IV	OH

General Provider Information

NPI Number	:	1730472358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH CAMPBELL JR. LPN

Provider Business Mailing Address
First Line	:	18317 LEWIS DR
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-2734
Country	:	US
Telephone Number	:	216-630-4713
Fax Number	:

Provider Business Practice Location Address
First Line	:	18317 LEWIS DR
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-2734
Country	:	US
Telephone Number	:	216-630-4713
Fax Number	:

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

Provider Enumeration Date	:	05/16/2011
Last Update Date	:	05/16/2011

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