Healthcare Provider Details

I. General information

NPI: 1841423886
Provider Name (Legal Business Name): RUBENS HENRIQUE DACOSTA SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2D MARINE SPECIAL OPERATIONS BATTALION PSC
CAMP LEJEUNE NC
28542-0183
US

IV. Provider business mailing address

306 HEADWATERS DR
HAMPSTEAD NC
28443-2085
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7704
  • Fax: 910-440-7059
Mailing address:
  • Phone: 910-546-3112
  • Fax: 910-450-4194

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: