Healthcare Provider Details

I. General information

NPI: 1942543988
Provider Name (Legal Business Name): NAVY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SMITH RD
NEWPORT RI
02841-1006
US

IV. Provider business mailing address

43 SMITH RD
NEWPORT RI
02841
US

V. Phone/Fax

Practice location:
  • Phone: 631-745-7381
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1103X
TaxonomyMilitary Ambulatory Procedure Visits Operational (Transportable) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OMAR SANTIAGO RODAS
Title or Position: E2/HA
Credential:
Phone: 631-745-7381