=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659985695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC LEE WOODWORTH SOIDC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2020
-----------------------------------------------------
Last Update Date | 09/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | A66 BOAT BASIN ROAD
-----------------------------------------------------
City | CAMP LEJEUNE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-440-7714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120A JAMES AVE
-----------------------------------------------------
City | HOLLY RIDGE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28445-7037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-474-7079
-----------------------------------------------------
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 |
-----------------------------------------------------