Healthcare Provider Details

I. General information

NPI: 1578829826
Provider Name (Legal Business Name): MICHAEL STEVEN ELLIOTT SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST MARINE SPECIAL OPERATIONS BTN. BOX 555341
CAMP PENDLETON CA
92055-5341
US

IV. Provider business mailing address

1ST MARINE SPECIAL OPERATIONS BTN. CAMP PENDLETON, CA 92055
APO AP
92055
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-5298
  • Fax:
Mailing address:
  • Phone: 509-780-1453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number10126925ME
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: