Healthcare Provider Details

I. General information

NPI: 1649478405
Provider Name (Legal Business Name): JON DOUGLAS CUCURA R.D./CDCES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVENUE
FORT BRAGG NC
28310-2745
US

IV. Provider business mailing address

2817 ROCK MERRITT AVENUE
FORT LIBERTY NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-6335
  • Fax: 910-907-7632
Mailing address:
  • Phone: 910-907-6335
  • Fax: 910-907-7632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL002136
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: