Healthcare Provider Details

I. General information

NPI: 1063460210
Provider Name (Legal Business Name): NEILROSE LACISTE GERVACIO IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAMP SCHWAB BMC 3D MED BN, 3D MLG, C CO
FPO AP
96604
US

IV. Provider business mailing address

PSC 557 BOX 2631
FPO AP
96379
US

V. Phone/Fax

Practice location:
  • Phone: 011816117252272
  • 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: