Provider Demographics
NPI:1467000901
Name:COULOMBE, RYAN JACKSON (SUBMARINE IDC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JACKSON
Last Name:COULOMBE
Suffix:
Gender:M
Credentials:SUBMARINE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 THE LN
Mailing Address - Street 2:
Mailing Address - City:LUNENBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01462-1800
Mailing Address - Country:US
Mailing Address - Phone:978-855-2432
Mailing Address - Fax:
Practice Address - Street 1:22 THE LN
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462-1800
Practice Address - Country:US
Practice Address - Phone:978-855-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman