Healthcare Provider Details

I. General information

NPI: 1649447244
Provider Name (Legal Business Name): PAUL RICKY ENA IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 13129, 14 TH ST
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

NHCP BLDG H-100 SANTA MARGARITA RD
CAMP PENDLETON CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-2194
  • Fax:
Mailing address:
  • Phone: 760-763-6529
  • 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: