Healthcare Provider Details

I. General information

NPI: 1235735267
Provider Name (Legal Business Name): KYLE WESTON HOLBROOK IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2020
Last Update Date: 06/17/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 308 HM SMITH BLVD
CAMP LEJUENE NC
28539
US

IV. Provider business mailing address

BLDG 308 HM SMITH BLVD
CAMP LEJUENE NC
28539
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4300
  • Fax:
Mailing address:
  • Phone: 910-450-4300
  • 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: