Provider Demographics
NPI:1013468859
Name:CAMPBELL, DALTON (ATC)
Entity type:Individual
Prefix:
First Name:DALTON
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 1:11490 CLEAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-9701
Mailing Address - Country:US
Mailing Address - Phone:850-501-1999
Mailing Address - Fax:
Practice Address - Street 1:11490 CLEAR CREEK DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-9701
Practice Address - Country:US
Practice Address - Phone:850-501-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL45402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer