Healthcare Provider Details

I. General information

NPI: 1932516473
Provider Name (Legal Business Name): CORY BARROW NAVY IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY COURT
CAMP PENDLETON SOUTH CA
92055
US

IV. Provider business mailing address

2846 FALVY AVE
SAN DIEGO CA
92111-5811
US

V. Phone/Fax

Practice location:
  • Phone: 909-224-1056
  • Fax:
Mailing address:
  • Phone: 909-224-1056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License NumberB-300-0019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: