Basic Information
| Provider Information | |||||||||
| NPI: | 1639402779 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMPUS CLINICS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CAMPUS CLINICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1901 10TH AVE | ||||||||
| Address2: | CAMPUS BOX 37 | ||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806395545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703512412 | ||||||||
| FaxNumber: | 9703512427 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 10TH AVE | ||||||||
| Address2: | CAMPUS BOX 37 | ||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806395545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703512412 | ||||||||
| FaxNumber: | 9703512427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2009 | ||||||||
| LastUpdateDate: | 09/08/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GINN | ||||||||
| AuthorizedOfficialFirstName: | NATHAN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9703512412 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.C. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NR0400X | 5112 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | Rehabilitation | 208D00000X | 32068 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.