Healthcare Provider Details

I. General information

NPI: 1699987438
Provider Name (Legal Business Name): U.S. MARINE CORPS FORCES COMMAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CLR-27, 2D MLG, PSC BOX 20125 BLDG 308, HOLCOLM BLVD.
CAMP LEJEUNE NC
28542
US

IV. Provider business mailing address

HEALTH SERVICES SUPPORT 1468 INGRAM ST
NORFOLK VA
23551-2596
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-6672
  • Fax:
Mailing address:
  • Phone: 757-836-1685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License NumberMD-6125
License Number StateHI

VIII. Authorized Official

Name: DR. MICHAEL SCOTT MOELLER
Title or Position: GROUP SURGEON, 2D MARINE LOG GRP
Credential: MD
Phone: 910-450-6672