Provider Demographics
NPI:1417028820
Name:CAMPOS, ERNESTO R (OT)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:R
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-6011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1630 E REELFOOT AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-6021
Practice Address - Country:US
Practice Address - Phone:731-885-8095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2458225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist