Healthcare Provider Details

I. General information

NPI: 1295872232
Provider Name (Legal Business Name): BYRON PACK IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533020 BASOLINE RD CAMP HORNO
CAMP PENDLETON CA
92055-5402
US

IV. Provider business mailing address

3627 W THORNTON AVE
HEMET CA
92545-9129
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-7410
  • Fax: 760-725-7663
Mailing address:
  • Phone: 951-766-2798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: