Provider Demographics
NPI:1770850752
Name:BEAUCHAMP, DARRYL GLENN JR (SPECIAL OPS IDC)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:GLENN
Last Name:BEAUCHAMP
Suffix:JR
Gender:M
Credentials:SPECIAL OPS IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3D MARINE SPECIAL OPERATIONS BATTALION
Mailing Address - Street 2:PSC BOX 20073
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0073
Mailing Address - Country:US
Mailing Address - Phone:910-449-9967
Mailing Address - Fax:
Practice Address - Street 1:3D MARINE SPECIAL OPERATIONS BATTALION
Practice Address - Street 2:PSC BOX 20073
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0073
Practice Address - Country:US
Practice Address - Phone:910-449-9967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman