Basic Information
Provider Information | |||||||||
NPI: | 1750676938 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHILDERS | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 357054 | ||||||||
Address2: | SAN CLEMENTE ISLAND BRANCH MEDICAL CLINIC | ||||||||
City: | FPO | ||||||||
State: | AP | ||||||||
PostalCode: | 921357054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195249356 | ||||||||
FaxNumber: | 6195249207 | ||||||||
Practice Location | |||||||||
Address1: | SEAL TEAM THREE MEDICAL | ||||||||
Address2: | 2642 TRIDENT WAY | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921555492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195249356 | ||||||||
FaxNumber: | 6195249207 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2011 | ||||||||
LastUpdateDate: | 06/15/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1002X |   |   | Y |   | Other Service Providers | Military Health Care Provider | Independent Duty Corpsman |
No ID Information.