Healthcare Provider Details

I. General information

NPI: 1306653951
Provider Name (Legal Business Name): CODY GABLE DAVIS SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST RECON BN, BAS P.O. BOX #555584
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

1ST RECON BN, BAS P.O. BOX #555584
CAMP PENDLETON CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-8912
  • Fax:
Mailing address:
  • Phone: 760-725-8912
  • 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: