Basic Information
| Provider Information | |||||||||
| NPI: | 1861691115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | CULLEN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | L.S.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5219 CITY BANK PKWY STE 35 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794073545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067610333 | ||||||||
| FaxNumber: | 8067929180 | ||||||||
| Practice Location | |||||||||
| Address1: | 3502 9TH ST STE 260 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794155305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067928185 | ||||||||
| FaxNumber: | 8067929180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246XC2903X | SA00109 | TX | N | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Cardiovascular | Vascular Specialist | 246ZC0007X | SA00109 | TX | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
ID Information
| ID | Type | State | Issuer | Description | 109783100 | 01 | FIRST CARE | OTHER |