Healthcare Provider Details

I. General information

NPI: 1386675833
Provider Name (Legal Business Name): CALVIN LAMONT BAILEY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4TH & INNER LOOP BLDG 166
FT IRWIN CA
92310
US

IV. Provider business mailing address

BLDG 106 LANGFORD LAKE RD ROOM 207
FT IRWIN CA
92310
US

V. Phone/Fax

Practice location:
  • Phone: 760-380-4013
  • Fax:
Mailing address:
  • Phone: 760-386-3538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001155641
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: