Healthcare Provider Details

I. General information

NPI: 1154920940
Provider Name (Legal Business Name): KYLE LEO PRICE SUBMARINE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 05/19/2022
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS OKLAHOMA CITY
APO AP
96932
US

IV. Provider business mailing address

USS OKLAHOMA CITY
APO AP
96932
US

V. Phone/Fax

Practice location:
  • Phone: 765-490-8819
  • Fax:
Mailing address:
  • Phone:
  • 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: