Healthcare Provider Details

I. General information

NPI: 1972808194
Provider Name (Legal Business Name): BERNADETTE CONLIN OHARA CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 HENDERSON DR
JACKSONVILLE NC
28540-5601
US

IV. Provider business mailing address

PO BOX 752
JACKSONVILLE NC
28541-0752
US

V. Phone/Fax

Practice location:
  • Phone: 910-938-2004
  • Fax: 910-938-2018
Mailing address:
  • Phone: 910-938-2004
  • Fax: 910-938-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number2137
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: