Provider Demographics
NPI:1598141459
Name:CAMPBELL, DUSTIN (ATC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 HARDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-5918
Mailing Address - Country:US
Mailing Address - Phone:863-687-1250
Mailing Address - Fax:
Practice Address - Street 1:2611 JENNIFER DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-5130
Practice Address - Country:US
Practice Address - Phone:863-450-5496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL22472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer