Healthcare Provider Details

I. General information

NPI: 1275113128
Provider Name (Legal Business Name): NICHOLAS FARRIS SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 04/13/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 STUART MESA ROAD
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

1ST RECONNAISSANCE BATTALION, PSC BOX 555584 4101 STUART MESA ROAD
CAMP PENDLETON CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 760-763-2118
  • Fax:
Mailing address:
  • Phone: 540-446-9171
  • 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: