Healthcare Provider Details

I. General information

NPI: 1013123405
Provider Name (Legal Business Name): JAMES JON RUANE 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

6935 LIVERPOOL CT NE
BREMERTON WA
98311-9646
US

IV. Provider business mailing address

1400 FARRAGUT AVE. BLDG 940
BREMERTON WA
98312
US

V. Phone/Fax

Practice location:
  • Phone: 360-476-6872
  • Fax:
Mailing address:
  • Phone: 360-476-6872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number17101002X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: