Provider Demographics
NPI:1659598274
Name:DEVINE, JOHN C
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:DEVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CGC VIGILANT (WMEC-617)
Mailing Address - Street 2:9235 GROUPER ROAD
Mailing Address - City:PORT CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920
Mailing Address - Country:US
Mailing Address - Phone:321-853-7176
Mailing Address - Fax:321-784-0382
Practice Address - Street 1:CGC VIGILANT (WMEC-617)
Practice Address - Street 2:9235 GROUPER ROAD
Practice Address - City:PORT CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920
Practice Address - Country:US
Practice Address - Phone:321-853-7176
Practice Address - Fax:321-784-0382
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman