Healthcare Provider Details

I. General information

NPI: 1790976496
Provider Name (Legal Business Name): 2ND MARINE DIVISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FRENCH CREEK GAS, CLR 27, 2ND MLG
CAMP LEJUENE NC
28547
US

IV. Provider business mailing address

1802 HARRIETTE DR
KINSTON NC
28504-6722
US

V. Phone/Fax

Practice location:
  • Phone: 910-451-5125
  • Fax:
Mailing address:
  • Phone: 252-522-4895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1102X
TaxonomyMilitary Outpatient Operational (Transportable) Component Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GEORGE SEMPLE
Title or Position: DIVISION SURGEON
Credential: MD
Phone: 910-451-8372