Healthcare Provider Details

I. General information

NPI: 1609556273
Provider Name (Legal Business Name): JACOB BAGLEY SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COURTHOUSE RD BUILDING A66
CAMP LEJEUNE NC
28547
US

IV. Provider business mailing address

5185 COLORADO AVE
CAMP LEJEUNE NC
28547-1126
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7925
  • Fax:
Mailing address:
  • Phone: 412-780-8250
  • 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: