Healthcare Provider Details

I. General information

NPI: 1225005515
Provider Name (Legal Business Name): CHARLES THOMAS CANTERBURY HMCS - NAVY IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2006
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SECOND MEDICAL BATTALION, 2D MARINE LOGISTICS GROUP PSC BOX 20129
CAMP LEJEUNE NC
28542-0129
US

IV. Provider business mailing address

SECOND MEDICAL BATTALION, 2D MARINE LOGISTICS GROUP PSC BOX 20129
CAMP LEJEUNE NC
28542-0129
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-7492
  • Fax:
Mailing address:
  • Phone: 910-450-7492
  • 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: