Healthcare Provider Details

I. General information

NPI: 1164033197
Provider Name (Legal Business Name): BRIAN DAVID BJERKE SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 EVERRETT CREEK ROAD
SNEAD'S FERRY NC
28460
US

IV. Provider business mailing address

257 EVERETT YOPP DR
SNEADS FERRY NC
28460-9449
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-1947
  • Fax:
Mailing address:
  • Phone: 248-835-5470
  • 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: