Provider Demographics
NPI:1275940777
Name:CAMPOS, WALTER (AS)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S KINGSLEY DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-2319
Mailing Address - Country:US
Mailing Address - Phone:213-201-1621
Mailing Address - Fax:213-201-1392
Practice Address - Street 1:611 S KINGSLEY DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-2319
Practice Address - Country:US
Practice Address - Phone:213-201-1621
Practice Address - Fax:213-201-1392
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator