=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568621787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | U S NAVY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2008
-----------------------------------------------------
Last Update Date | 06/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1550 TOMCAT BLVD SUITE 150
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23460-2218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-953-3774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1550 TOMCAT BLVD SUITE 150
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23460-2218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-953-3774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INDEPENDENT DUTY CORPSMAN
-----------------------------------------------------
Name | LARRY JASON FLINT
-----------------------------------------------------
Credential | IDC
-----------------------------------------------------
Telephone | 757-953-3774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QV0200X
-----------------------------------------------------
Taxonomy Name | VA Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------