Individual
MR. KENNETH LEE RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
NAVY SOIDC
Contact information
Practice address
3D MARINE RAIDER BATTALION, CAMP LEJEUNE, NC 28546
(360) 808-1590
Mailing address
1101 MAREN CV APT 102, SNEADS FERRY, NC 28460-0080
(360) 808-1590
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1391428740
NAVY/DOD
—
Enumeration date
05/31/2018
Last updated
05/31/2018
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