Healthcare Provider Details

I. General information

NPI: 1528635471
Provider Name (Legal Business Name): CHARLES TUCKER HALL SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2D MARINE DIVISION 2D RECONNAISSANCE BATTALION
CAMP LEJUNE NC
28542-0138
US

IV. Provider business mailing address

2D MARINE DIVISION, 2D RECONNAISSANCE BATTALION PSC BOX 20138
CAMP LEJUNE NC
28542-0138
US

V. Phone/Fax

Practice location:
  • Phone: 414-514-5304
  • Fax:
Mailing address:
  • Phone: 414-514-5304
  • 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: