Healthcare Provider Details

I. General information

NPI: 1306395280
Provider Name (Legal Business Name): UNITED STATES NAVY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING H 2005 KNIGHT LANE NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS
JACKSONVILLE FL
32212-0140
US

IV. Provider business mailing address

853 VALLEY AVE
SOLANA BEACH CA
92075-2492
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-3213
  • Fax:
Mailing address:
  • Phone: 631-948-3006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7136-15
License Number StateWI

VIII. Authorized Official

Name: DR. PETER RUOCCO
Title or Position: COMMANDING OFFICER
Credential:
Phone: 760-725-5208