MEDICARE: MR. JUSTIN RAY HARRIS SR. SFIDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1093923872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN RAY HARRIS SR. SFIDC

Provider Business Mailing Address
First Line	:	8549 CULFOR CRESCENT
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23503
Country	:	US
Telephone Number	:	757-839-3185
Fax Number	:

Provider Business Practice Location Address
First Line	:	581 'A' STREET
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23511-2133
Country	:	US
Telephone Number	:	757-443-0026
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	06/22/2012

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