Healthcare Provider Details

I. General information

NPI: 1508873092
Provider Name (Legal Business Name): EDWIN SOTO IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COMBAT LOGISTICS REGIMENT 27 2D MARINE LOGISTICS GROUP, PSC BOX 20125
CAMP LEJEUNE NC
28542-0125
US

IV. Provider business mailing address

1003 PINE VALLEY RD
JACKSONVILLE NC
28546-1647
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-6673
  • Fax:
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: