Healthcare Provider Details

I. General information

NPI: 1699294686
Provider Name (Legal Business Name): MICHAEL HER IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 09/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 100281 BOX 1 FPO AE 09588-1900
BAHRAIN FOREIGN PROVINCE
MANAMA
BH

IV. Provider business mailing address

8882 PROMENADE NORTH PL
SAN DIEGO CA
92123-6456
US

V. Phone/Fax

Practice location:
  • Phone: 559-283-5541
  • Fax:
Mailing address:
  • Phone: 559-283-5541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: