MEDICARE: LBN HARRISON CAMPBELL DC LLC

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	261Q00000X	Clinic/Center
2	111N00000X	Chiropractor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13294	OTHER	TX	LICENSE

General Provider Information

NPI Number	:	1760038889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LBN HARRISON CAMPBELL DC LLC

Provider Business Mailing Address
First Line	:	2121 WILLIAMS TRACE BLVD STE 300
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77478-4526
Country	:	US
Telephone Number	:	281-344-2034
Fax Number	:	281-783-2002

Provider Business Practice Location Address
First Line	:	2121 WILLIAMS TRACE BLVD STE 300
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77478-4526
Country	:	US
Telephone Number	:	281-344-2034
Fax Number	:	281-783-2002

Authorized Official
Title or Position	:	DOCTOR/OWNER
Name	:	HARRISON KYLE CAMPBELL
Credential	:	DC
Telephone Number	:	281-344-0344

Provider Enumeration Date	:	08/14/2019
Last Update Date	:	01/13/2021

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