Healthcare Provider Details

I. General information

NPI: 1609557313
Provider Name (Legal Business Name): JUSTIN GREGORY KOREN SO-ATP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 07/26/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2D MARDIV 2D RECONNAISSANCE BN
APO AA
28542-0138
US

IV. Provider business mailing address

2D MARDIV 2D RECONNAISSANCE BN, CAMP LEJEUNE
APO AA
28542-0138
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7703
  • Fax:
Mailing address:
  • Phone: 910-440-7703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: