Provider Demographics
NPI:1669606802
Name:CAIN, ANGIE (IDMT)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:CAIN
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 MEDICAL GROUP
Mailing Address - Street 2:77 NEALLY AVE
Mailing Address - City:JOINT BASE LANGLEY-EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2040
Mailing Address - Country:US
Mailing Address - Phone:757-764-2109
Mailing Address - Fax:
Practice Address - Street 1:633 MEDICAL GROUP
Practice Address - Street 2:77 NEALLY AVE
Practice Address - City:JOINT BASE LANGLEY-EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-764-2109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians