=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215591888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NASH RICHARD GALVAN IDC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2019
-----------------------------------------------------
Last Update Date | 04/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 456-462 POCAHONTAS ST
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-445-5446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | USS STOUT (DDG 55 ) UNIT 100290, BOX 1
-----------------------------------------------------
City | FPO
-----------------------------------------------------
State | AE
-----------------------------------------------------
Zip | 09587-1273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-444-8814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1710I1002X
-----------------------------------------------------
Taxonomy Name | Independent Duty Corpsman
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------