Healthcare Provider Details

I. General information

NPI: 1033398342
Provider Name (Legal Business Name): BRANDON BALISACAN DELA CRUZ IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

D STREET BUILDING 202
JACKSONVILLE NC
28542
US

IV. Provider business mailing address

PSC BOX 20101
CAMP LEJEUNE NC
28542
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-6109
  • Fax:
Mailing address:
  • Phone: 910-450-6109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: