Healthcare Provider Details

I. General information

NPI: 1053263319
Provider Name (Legal Business Name): DEVIN TAYLOR RIVET ATP - SOCM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2026
Last Update Date: 02/10/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 NORMANDY DR, FORT BRAGG, NC, 28310
APO AA
28310
US

IV. Provider business mailing address

843 NORMANDY DR, FORT BRAGG, NC, 28310
APO AA
28310
US

V. Phone/Fax

Practice location:
  • Phone: 910-432-8193
  • Fax: 910-907-2778
Mailing address:
  • Phone: 910-432-8193
  • Fax: 910-907-2778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number06205177DR
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: