Provider Demographics
NPI:1720438500
Name:CAMPBELL, LEDILLA
Entity Type:Individual
Prefix:
First Name:LEDILLA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 CARNELIAN CT
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-7291
Mailing Address - Country:US
Mailing Address - Phone:951-358-6031
Mailing Address - Fax:
Practice Address - Street 1:3807 CARNELIAN CT
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-7291
Practice Address - Country:US
Practice Address - Phone:951-358-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA639352171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA225195Medicaid