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General NPI Number Information
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NPI Number | 1023739315
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Entity Type | Individual
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Provider Name | BRANDON TIMOTHY BAZELUK
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Gender | Male
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Dates
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Enumeration Date | 09/06/2022
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Last Update Date | 03/10/2023
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Provider Practice Location Address
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Address Line | 210 KYLE DR
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City | HAVELOCK
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State | NC
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Zip | 28532-1773
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Country | US
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Telephone | 630-297-6750
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Fax |
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Provider Business Mailing Address
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Address Line | 34101 FARENHOLT AVE
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City | SAN DIEGO
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State | CA
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Zip | 92134-7000
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1710I1002X
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Taxonomy Name | Independent Duty Corpsman
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License Number |
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License Number State |
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