Healthcare Provider Details

I. General information

NPI: 1154611978
Provider Name (Legal Business Name): WINDELL CURTIS KELLOGG IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JUNGLE WARFARE TRAINING CENTER, CAMP GONSALVES UNIT 3591
FPO AP
96602
US

IV. Provider business mailing address

JUNGLE WARFARE TRAINING CENTER, CAMP GONSALVES UNIT 3591
FPO AP
96602
US

V. Phone/Fax

Practice location:
  • Phone: 361-249-8803
  • 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: