Healthcare Provider Details

I. General information

NPI: 1053082651
Provider Name (Legal Business Name): EDWARD REGIS NEVILLE SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 04/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3D RECON BAS
FPO AP
96389
US

IV. Provider business mailing address

3D RECON BN AID STATION
FPO AP
96389-6189
US

V. Phone/Fax

Practice location:
  • Phone: 917-943-0666
  • Fax:
Mailing address:
  • Phone: 917-943-0666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code261QM1103X
TaxonomyMilitary Ambulatory Procedure Visits Operational (Transportable) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: