Healthcare Provider Details

I. General information

NPI: 1700170859
Provider Name (Legal Business Name): DENNIS PANSACOLA RAYMUNDO SFIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

H100 SANTA MARGARITA RD NAVAL HOSPITAL CAMP PENDLETON
OCEAN SIDE CA
92058
US

IV. Provider business mailing address

35463 SUGAR MAPLE ST
MURRIETA CA
92563-7942
US

V. Phone/Fax

Practice location:
  • Phone: 760-763-6529
  • Fax:
Mailing address:
  • Phone: 619-764-3059
  • 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: