Healthcare Provider Details

I. General information

NPI: 1205048501
Provider Name (Legal Business Name): JEAN MARC DUBE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SPECIAL BOAT TEAM TWENTY TWO 2603 LOWER GAINESVILLE ROAD
STENNIS SPACE CENTER MS
39529-0001
US

IV. Provider business mailing address

SPECIAL BOAT TEAM TWENTY TWO 2603 LOWER GAINESVILLE ROAD
STENNIS SPACE CENTER MS
39529-0001
US

V. Phone/Fax

Practice location:
  • Phone: 228-813-4000
  • Fax: 228-813-4021
Mailing address:
  • Phone: 228-813-4000
  • Fax: 228-813-4021

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: