Healthcare Provider Details

I. General information

NPI: 1144103292
Provider Name (Legal Business Name): HAARIS GEORGE BJOTVEDT SOIDC (SO-ATP)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2D MARINE RAIDER BATTALION BATTALION AID STATION, PSC BOX 20183
CAMP LEJEUNE NC
28542-0183
US

IV. Provider business mailing address

409 RIDGEWAY DR
SNEADS FERRY NC
28460-7613
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7704
  • Fax:
Mailing address:
  • Phone: 602-809-0298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number10243398HB
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: