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General NPI Number Information
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NPI Number | 1144103292
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Entity Type | Individual
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Provider Name | HAARIS GEORGE BJOTVEDT SOIDC (SO-ATP)
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Gender | Male
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Dates
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Enumeration Date | 07/28/2025
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Last Update Date | 07/28/2025
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Provider Practice Location Address
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Address Line | 2D MARINE RAIDER BATTALION BATTALION AID STATION, PSC BOX 20183
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City | CAMP LEJEUNE
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State | NC
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Zip | 28542-0183
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Country | US
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Telephone | 910-440-7704
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Fax |
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Provider Business Mailing Address
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Address Line | 409 RIDGEWAY DR
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City | SNEADS FERRY
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State | NC
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Zip | 28460-7613
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Country | US
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Telephone | 602-809-0298
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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 | 10243398HB
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License Number State | NC
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