Provider Demographics
NPI:1265948616
Name:CAMPBELL, BYRON (LAT, PT)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:LAT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 BROAD ST # 203
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3006
Mailing Address - Country:US
Mailing Address - Phone:352-989-5838
Mailing Address - Fax:352-404-8979
Practice Address - Street 1:1804 OAKLEY SEAVER DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1925
Practice Address - Country:US
Practice Address - Phone:352-989-5838
Practice Address - Fax:352-404-8979
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00010352255A2300X
FLPT37819225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer