Healthcare Provider Details

I. General information

NPI: 1407100191
Provider Name (Legal Business Name): COREY LAMEL SPRINGS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 A ST APT 3
SAN DIEGO CA
92102-2124
US

IV. Provider business mailing address

2631 A ST APT 3
SAN DIEGO CA
92102-2124
US

V. Phone/Fax

Practice location:
  • Phone: 619-549-7429
  • Fax:
Mailing address:
  • Phone: 619-549-7429
  • 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: