MEDICARE: MR. CHARLES EDWARD GIVENS JR. IDC

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	:	1346421914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES EDWARD GIVENS JR. IDC

Provider Business Mailing Address
First Line	:	5501 MARVIN SHIELDS BLVD
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501-9007
Country	:	US
Telephone Number	:	228-871-2810
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 MARVIN SHIELDS BLVD
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501-9007
Country	:	US
Telephone Number	:	228-871-2810
Fax Number	:

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

Provider Enumeration Date	:	11/23/2007
Last Update Date	:	01/07/2009

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