Provider Demographics
NPI:1922690072
Name:BRANCH, THEODORE SHERMAN
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:SHERMAN
Last Name:BRANCH
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:COMMANDING OFFICER 2D RECONNAISSANCE BATTALION
Mailing Address - Street 2:PSC BOX 20138
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0138
Mailing Address - Country:US
Mailing Address - Phone:910-440-7703
Mailing Address - Fax:
Practice Address - Street 1:COMMANIND OFFCER 2D RECONNAISSANCE BATTALION
Practice Address - Street 2:
Practice Address - City:CAMP LEJUENE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:201-951-8952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman