Healthcare Provider Details

I. General information

NPI: 1245596832
Provider Name (Legal Business Name): GARRETT BLAZE DEARING SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 04/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 4130077 EAST MARSOC 1ST MARINE SPECIAL OPERATIONS BATALLION
CAMP PENDLETON CA
92055-5020
US

IV. Provider business mailing address

BLDG 4130077 EAST MARSOC 1ST MARINE SPECIAL OPERATIONS BATALLION
CAMP PENDLETON CA
92055-5020
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-5298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: