Healthcare Provider Details

I. General information

NPI: 1043427396
Provider Name (Legal Business Name): MICHAEL CHAD GANDY IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ANTI-TERRORISM BATTALION, 2ND MARINE DIVISION UNIT 20165
CAMP LEJEUNE NC
28542-0165
US

IV. Provider business mailing address

234 BROOKSTONE WAY
JACKSONVILLE NC
28546-9539
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-9431
  • Fax: 910-450-9223
Mailing address:
  • Phone:
  • 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: