Provider Demographics
NPI:1992849780
Name:CAMPBELL, KEVIN SCOTT SR
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SCOTT
Last Name:CAMPBELL
Suffix:SR
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 1:722 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427
Mailing Address - Country:US
Mailing Address - Phone:985-730-4357
Mailing Address - Fax:985-730-5267
Practice Address - Street 1:722 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427
Practice Address - Country:US
Practice Address - Phone:985-730-4357
Practice Address - Fax:985-730-5267
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA224P00000X, 225000000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440994Medicaid
LA1561312Medicaid
LA7214531530OtherBLUE CROSS BLUE SHIELD
MS7214531530OtherBLUE CROSS BLUE SHIELD
MS7214531530OtherBLUE CROSS BLUE SHIELD
MS00440994Medicaid