Provider Demographics
NPI:1487953444
Name:PALLESCO, ENRIQUE TOMENIO (SUBMARINE IDC)
Entity type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:TOMENIO
Last Name:PALLESCO
Suffix:
Gender:M
Credentials:SUBMARINE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16349 SMITHIFELD HEIGHTS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430
Mailing Address - Country:US
Mailing Address - Phone:757-771-1162
Mailing Address - Fax:
Practice Address - Street 1:16349 SMITHFIELD HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:VA
Practice Address - Zip Code:23430-7096
Practice Address - Country:US
Practice Address - Phone:757-771-1162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman