Provider Demographics
NPI:1952744641
Name:R BRET CAMPBELL DO & ASSOC LLC
Entity Type:Organization
Organization Name:R BRET CAMPBELL DO & ASSOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OSTEOPATHY
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:BRET
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-878-9432
Mailing Address - Street 1:1404 POMERELLE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2688
Mailing Address - Country:US
Mailing Address - Phone:208-878-9432
Mailing Address - Fax:208-878-4576
Practice Address - Street 1:1501 HILAND AVE STE A
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2688
Practice Address - Country:US
Practice Address - Phone:208-878-9432
Practice Address - Fax:208-878-4576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1124041116Medicaid
ID1124041116Medicaid