Healthcare Provider Details

I. General information

NPI: 1750631685
Provider Name (Legal Business Name): US NAVY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 HICKORY DR
GROTON CT
06340-2946
US

IV. Provider business mailing address

207 HICKORY DR
GROTON CT
06340-2946
US

V. Phone/Fax

Practice location:
  • Phone: 361-522-5925
  • Fax:
Mailing address:
  • Phone: 361-522-5925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. ISMAEL ARTURO LOPEZ
Title or Position: SUB IDC
Credential: SUB IDC
Phone: 361-522-5925