Provider Demographics
NPI:1578765681
Name:CASSELL, CHRIS BLANE (MILITARY IDC)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:BLANE
Last Name:CASSELL
Suffix:
Gender:M
Credentials:MILITARY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 OAK GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539-3435
Mailing Address - Country:US
Mailing Address - Phone:910-450-7719
Mailing Address - Fax:
Practice Address - Street 1:PSC BOX 20138
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0138
Practice Address - Country:US
Practice Address - Phone:910-450-7719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCATP03016789CC1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman