Healthcare Provider Details

I. General information

NPI: 1922209204
Provider Name (Legal Business Name): STEVEN LEE BLEDSOE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CLR-17 RAS, 1ST MLG BLDG 14030
CAMP PENDLETON CA
92055-5607
US

IV. Provider business mailing address

CLR-17 RAS, 1ST MLG PO BOX 555607
CAMP PENDLETON CA
92055-5607
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-6180
  • Fax:
Mailing address:
  • Phone: 760-725-6180
  • 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: