Healthcare Provider Details

I. General information

NPI: 1639147689
Provider Name (Legal Business Name): GEORGE LEO KROW JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL CAMP LEJEUNE 100 BREWSTER BLVD
CAMP LEJEUNE NC
28542-2538
US

IV. Provider business mailing address

104 LANCE CT
JACKSONVILLE NC
28546-8640
US

V. Phone/Fax

Practice location:
  • Phone: 910-451-1053
  • Fax:
Mailing address:
  • Phone: 910-989-1075
  • 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: