Provider Demographics
NPI:1235764234
Name:CAMPBELL, MACK LEE
Entity Type:Individual
Prefix:
First Name:MACK
Middle Name:LEE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3634 MARBLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2228
Mailing Address - Country:US
Mailing Address - Phone:573-718-0971
Mailing Address - Fax:
Practice Address - Street 1:3634 MARBLE HILL RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2228
Practice Address - Country:US
Practice Address - Phone:573-718-0971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver