Provider Demographics
NPI:1053082651
Name:NEVILLE, EDWARD REGIS (SOIDC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:REGIS
Last Name:NEVILLE
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3D RECON BN AID STATION
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96389-6189
Mailing Address - Country:US
Mailing Address - Phone:917-943-0666
Mailing Address - Fax:
Practice Address - Street 1:3D RECON BAS
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96389
Practice Address - Country:US
Practice Address - Phone:917-943-0666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 261QM1103X
NY171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1103XAmbulatory Health Care FacilitiesClinic/CenterMilitary Ambulatory Procedure Visits Operational (Transportable)
No171000000XOther Service ProvidersMilitary Health Care Provider