Healthcare Provider Details

I. General information

NPI: 1669602298
Provider Name (Legal Business Name): CHRISTOPHER AVERY BARTLETT IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 455 BOX 152
FPO AP
96540-0152
US

IV. Provider business mailing address

17 HUTCHINS ST
SANTA RITA GU
96915-1163
US

V. Phone/Fax

Practice location:
  • Phone: 671-339-7143
  • Fax:
Mailing address:
  • Phone: 671-727-0836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number1710L1002X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: