Healthcare Provider Details

I. General information

NPI: 1356014831
Provider Name (Legal Business Name): STEVEN GORDON WINDERS SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 SW PLANTATION DR
MAPLE HILL NC
28454-7588
US

IV. Provider business mailing address

273 SW PLANTATION DR
MAPLE HILL NC
28454-7588
US

V. Phone/Fax

Practice location:
  • Phone: 619-817-6140
  • Fax:
Mailing address:
  • Phone: 619-817-6140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number12192611SW
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: