Doctor Name: | MR. LARRY ODELL NEELY |
NPI Number: | 1568719821 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | IDC |
License Number: | |
Business Practice Address: | 34101 Farenholt Ave Bldg 14 San Diego, CA - 921345291 |
Business Phone Number: | 6195326195 |
Business Fax Number: | |
Mailing Address: | 10125 Bordelon St, SAN DIEGO |
State: | CA |
Postal Code: | 921243204 |
Phone Number: | 8584440108 |
Fax Number: | |
NPI Enumeration Date: | 08/06/2012 |
NPI Last Update Date: | 08/06/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 171000000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Other Service Providers |
Taxonomy Classification: | Military Health Care Provider |
Taxonomy Specialization: | |
Taxonomy Definition: | Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes. |