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General NPI Number Information
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NPI Number | 1972791218
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Entity Type | Individual
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Provider Name | THEODORE HARRISON JR. IDC
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Gender | Male
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Dates
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Enumeration Date | 10/11/2007
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Last Update Date | 10/11/2007
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Provider Practice Location Address
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Address Line | 3020 SILVER CHARM CIR
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City | SUFFOLK
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State | VA
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Zip | 23435-3343
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Country | US
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Telephone | 757-375-5017
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Fax |
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Provider Business Mailing Address
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Address Line | 3020 SILVER CHARM CIR
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City | SUFFOLK
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State | VA
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Zip | 23435-3343
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Country | US
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Telephone | 757-375-5017
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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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