Healthcare Provider Details

I. General information

NPI: 1134331473
Provider Name (Legal Business Name): SALVADOR HERNANDEZ JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ATG WP PSC 473 BX 16 ENG DEPT.
YOKOSUKA KANAGAWA
96349
JP

IV. Provider business mailing address

4311 FLORENCE DR
JOHNSBURG IL
60051
US

V. Phone/Fax

Practice location:
  • Phone: 2436129
  • Fax:
Mailing address:
  • Phone: 181-535-4335
  • 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: