1063460210 NPI number — MR. NEILROSE LACISTE GERVACIO IDC

Table of content: MR. NEILROSE LACISTE GERVACIO IDC (NPI 1063460210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063460210 NPI number — MR. NEILROSE LACISTE GERVACIO IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GERVACIO
Provider First Name:
NEILROSE
Provider Middle Name:
LACISTE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063460210
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PSC 557 BOX 2631
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FPO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CAMP SCHWAB BMC
Provider Second Line Business Practice Location Address:
3D MED BN, 3D MLG, C CO
Provider Business Practice Location Address City Name:
FPO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
011816117252272
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1710I1002X . This is a "INDEPENDENT DUTY CORPSMAN" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com