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General NPI Number Information
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NPI Number | 1063460210
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Entity Type | Individual
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Provider Name | NEILROSE LACISTE GERVACIO IDC
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Gender | Male
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Dates
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Enumeration Date | 05/04/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | CAMP SCHWAB BMC 3D MED BN, 3D MLG, C CO
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City | FPO
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State | AP
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Zip | 96604
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Country | US
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Telephone | 011816117252272
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Fax |
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Provider Business Mailing Address
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Address Line | PSC 557 BOX 2631
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City | FPO
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State | AP
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Zip | 96379
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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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