Healthcare Provider Details

I. General information

NPI: 1922684422
Provider Name (Legal Business Name): ERIC ALEXANDER ARCHULETA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST MARINE RAIDER BATTALION, MARINE RAIDER REGIMENT 555341
APO AA
92055-5341
US

IV. Provider business mailing address

214 RANCHO DEL ORO DR APT 7
OCEANSIDE CA
92057-7303
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-5298
  • Fax:
Mailing address:
  • Phone: 925-818-1091
  • 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: