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General NPI Number Information
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NPI Number | 1881226637
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Entity Type | Individual
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Provider Name | CARLOS BOLIVAR PANCHANA
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Gender | Male
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Dates
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Enumeration Date | 02/10/2020
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Last Update Date | 02/10/2020
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Provider Practice Location Address
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Address Line | D ST #3089
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City | KAILUA
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State | HI
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Zip | 96734
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Country | US
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Telephone | 321-890-7187
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Fax |
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Provider Business Mailing Address
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Address Line | 10345 HOLDER WAY
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City | SAN DIEGO
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State | CA
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Zip | 92124-2512
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Country | US
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Telephone | 321-890-7187
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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 | CA
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