Provider Demographics
NPI:1669540555
Name:CAMPOS, RUDOLFO BRUCE
Entity type:Individual
Prefix:
First Name:RUDOLFO
Middle Name:BRUCE
Last Name:CAMPOS
Suffix:
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 1:114 MCCORMICK CANYON
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85533
Mailing Address - Country:US
Mailing Address - Phone:928-865-3109
Mailing Address - Fax:
Practice Address - Street 1:114 MCCORMICK CANYON
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:AZ
Practice Address - Zip Code:85533
Practice Address - Country:US
Practice Address - Phone:928-865-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ758287Medicaid