Provider Demographics
NPI:1700961778
Name:CAMPBELL, JUSTIN DALE (DC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DALE
Last Name:CAMPBELL
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 1:15495 N 247 RD
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-7969
Mailing Address - Country:US
Mailing Address - Phone:918-733-1351
Mailing Address - Fax:918-733-1353
Practice Address - Street 1:15495 N 247 RD
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-7969
Practice Address - Country:US
Practice Address - Phone:918-733-1351
Practice Address - Fax:918-733-1353
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3562111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
653268OtherACN GROUP, INC.
2591286OtherAETNA
2591286OtherAETNA