Healthcare Provider Details

I. General information

NPI: 1902544042
Provider Name (Legal Business Name): BOBBY RAY PHILLIPS JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3D MARINE RAIDER BATTALION, RR612 EVERETT CREEK RD
CAMP LEJEUNE NC
28542-0073
US

IV. Provider business mailing address

3D MARINE RAIDER BATTALION, PSC BOX 20073
CAMP LEJEUNE NC
28542-0073
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-1947
  • Fax:
Mailing address:
  • Phone: 910-440-1947
  • 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: