Healthcare Provider Details

I. General information

NPI: 1598951998
Provider Name (Legal Business Name): BDA CAMP LEJEUNE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD CODE 08/ZD
CAMP LEJEUNE NC
28547-2538
US

IV. Provider business mailing address

100 BREWSTER BLVD CODE 08/ZD
CAMP LEJEUNE NC
28547-2538
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4159
  • Fax: 910-450-4194
Mailing address:
  • Phone: 910-450-4159
  • Fax: 910-450-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHERYL L HAYNES
Title or Position: BUSINESS OFFICE MGT
Credential:
Phone: 910-450-4159