Healthcare Provider Details

I. General information

NPI: 1144820002
Provider Name (Legal Business Name): LEVI PARA SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2D RECONNAISSANCE BN PSC 20138
CAMP LEJEUNE NC
28452-0138
US

IV. Provider business mailing address

2110 W MCMANAMON RD
OTHELLO WA
99344-9027
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7703
  • Fax:
Mailing address:
  • Phone: 509-308-0864
  • 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: