Healthcare Provider Details

I. General information

NPI: 1871870022
Provider Name (Legal Business Name): KEN SAMUEL CONKLIN IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC BOX 20073 CAMP LEJEUNE, NC
APO AA
28542-0073
US

IV. Provider business mailing address

34101 FARENHOLT AVE
SAN DIEGO CA
92134-5291
US

V. Phone/Fax

Practice location:
  • Phone: 808-721-6299
  • Fax:
Mailing address:
  • Phone: 910-450-6324
  • 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: