Healthcare Provider Details

I. General information

NPI: 1114284809
Provider Name (Legal Business Name): RUDY J LOPEZ SO-IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JOINT SPECIAL OPERATIONS MEDICAL CTR USAJFKSWCS STOP A., 3004 ARDENNES ST.
FORT BRAGG NC
28310-9610
US

IV. Provider business mailing address

JOINT SPECIAL OPERATIONS MEDICAL CTR USAJFKSWCS STOP A., 3004 ARDENNES ST.
FORT BRAGG NC
28310-9610
US

V. Phone/Fax

Practice location:
  • Phone: 910-369-7775
  • Fax:
Mailing address:
  • Phone: 910-369-7775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License NumberNEC HM8403
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: