Provider Demographics
NPI:1700403961
Name:CAMPANILLA, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:CAMPANILLA
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 1:343 N CHEVY CHASE DR UNIT 4
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-5013
Mailing Address - Country:US
Mailing Address - Phone:818-731-8836
Mailing Address - Fax:
Practice Address - Street 1:630 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1008
Practice Address - Country:US
Practice Address - Phone:818-247-3395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant