Provider Demographics
NPI:1205986510
Name:CAMPOBASSO, JOSEPH MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:CAMPOBASSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 ARBOR GATE DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-5734
Mailing Address - Country:US
Mailing Address - Phone:815-254-8222
Mailing Address - Fax:
Practice Address - Street 1:2425 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:DIAMOND
Practice Address - State:IL
Practice Address - Zip Code:60416-9760
Practice Address - Country:US
Practice Address - Phone:815-634-0755
Practice Address - Fax:815-634-0756
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU78339Medicare UPIN