Basic Information
| Provider Information | |||||||||
| NPI: | 1437699865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPOS | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | MANUEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17800 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605526700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17800 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605526700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2017 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 25934 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.