Healthcare Provider Details

I. General information

NPI: 1558832345
Provider Name (Legal Business Name): NATHANIEL FRANKLIN CAMPBELL SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 612 EVERETT CREEK RD CAMP LEJUENE
FPO AE
28542
US

IV. Provider business mailing address

3208 PARAMOUNT WAY
WILMINGTON NC
28405-6457
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-1942
  • Fax:
Mailing address:
  • Phone: 707-972-9826
  • 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: