Healthcare Provider Details

I. General information

NPI: 1952517948
Provider Name (Legal Business Name): JAYCEE MORALES ENRIQUEZ IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL SUBMARINE SUPPORT CENTER 9168 SECOND STREET SUITE 202
NORFOLK VA
23511
US

IV. Provider business mailing address

NAVAL SUBMARINE SUPPORT CENTER 9168 SECOND STREET SUITE 202
NORFOLK VA
23511
US

V. Phone/Fax

Practice location:
  • Phone: 757-967-6175
  • Fax:
Mailing address:
  • Phone: 757-373-1278
  • 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: