Provider Demographics
NPI:1841423886
Name:DACOSTA, RUBENS HENRIQUE (SOIDC)
Entity Type:Individual
Prefix:MR
First Name:RUBENS
Middle Name:HENRIQUE
Last Name:DACOSTA
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 1:306 HEADWATERS DR
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-2085
Mailing Address - Country:US
Mailing Address - Phone:910-546-3112
Mailing Address - Fax:910-450-4194
Practice Address - Street 1:2D MARINE SPECIAL OPERATIONS BATTALION
Practice Address - Street 2:PSC
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0183
Practice Address - Country:US
Practice Address - Phone:910-440-7704
Practice Address - Fax:910-440-7059
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman