Provider Demographics
NPI:1518743178
Name:CAMPBELL, TAVARES
Entity Type:Individual
Prefix:
First Name:TAVARES
Middle Name:
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 1:89 ROCHELA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-4670
Mailing Address - Country:US
Mailing Address - Phone:860-781-1973
Mailing Address - Fax:
Practice Address - Street 1:89 ROCHELA DR
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-4670
Practice Address - Country:US
Practice Address - Phone:860-781-1973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0002272376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty