Healthcare Provider Details

I. General information

NPI: 1437347317
Provider Name (Legal Business Name): LEO BORISOVICH BUGAEFF I IDC/RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4643 DOCK RD BLDG 524
PORT HUENEME CA
93043-4378
US

IV. Provider business mailing address

4643 DOCK RD BLDG 524
PORT HUENEME CA
93043-4321
US

V. Phone/Fax

Practice location:
  • Phone: 805-982-2464
  • Fax:
Mailing address:
  • Phone: 805-982-2464
  • 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: