Healthcare Provider Details

I. General information

NPI: 1063645208
Provider Name (Legal Business Name): SHANE JEROME SEERY I.D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2009
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 632044 CHRISTIANITOS ROAD NAVAL EXPEDITIONARY MEDICAL TRAINING INSTITUTE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

PSC BOX 555223 NAVAL EXPEDITIONARY MEDICAL TRAINING INSTITUTE
CAMP PENDLETON CA
92055-5223
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-7121
  • Fax:
Mailing address:
  • Phone: 760-725-7121
  • 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: