Provider Demographics
NPI:1760046189
Name:CAMPOS, LISA (RSLD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:RSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11605 N LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-2658
Mailing Address - Country:US
Mailing Address - Phone:737-222-6996
Mailing Address - Fax:
Practice Address - Street 1:5822 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3712
Practice Address - Country:US
Practice Address - Phone:323-781-2208
Practice Address - Fax:323-541-9645
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6259156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician