Healthcare Provider Details

I. General information

NPI: 1003444928
Provider Name (Legal Business Name): ANDRES MARTIN RODONI SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2ND RECONNAISSANCE BATTALION
CAMP LEJUNE NC
28542
US

IV. Provider business mailing address

2ND RECONNAISSANCE BATTALION
CAMP LEJUNE NC
28542
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7703
  • Fax:
Mailing address:
  • Phone: 910-440-7703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: