Provider Demographics
NPI:1033353529
Name:EL, RETH (IDMT)
Entity Type:Individual
Prefix:MR
First Name:RETH
Middle Name:
Last Name:EL
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 BENNETT AVE
Mailing Address - Street 2:1SOSS/OSM
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-5707
Mailing Address - Country:US
Mailing Address - Phone:850-884-1168
Mailing Address - Fax:
Practice Address - Street 1:113 HOWIE WALTERS RD
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5668
Practice Address - Country:US
Practice Address - Phone:850-884-1168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians