Healthcare Provider Details

I. General information

NPI: 1295298172
Provider Name (Legal Business Name): JAMES GILL DEEP SEA DIVING IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 SHOUP DR
SAN DIEGO CA
92110-4866
US

IV. Provider business mailing address

2825 SHOUP DR
SAN DIEGO CA
92110-4866
US

V. Phone/Fax

Practice location:
  • Phone: 918-605-1335
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: