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General NPI Number Information
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NPI Number | 1609556273
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Entity Type | Individual
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Provider Name | JACOB BAGLEY SOIDC
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Gender | Male
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Dates
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Enumeration Date | 07/19/2023
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Last Update Date | 07/19/2023
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Provider Practice Location Address
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Address Line | COURTHOUSE RD BUILDING A66
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City | CAMP LEJEUNE
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State | NC
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Zip | 28547
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Country | US
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Telephone | 910-440-7925
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Fax |
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Provider Business Mailing Address
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Address Line | 5185 COLORADO AVE
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City | CAMP LEJEUNE
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State | NC
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Zip | 28547-1126
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Country | US
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Telephone | 412-780-8250
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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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