MEDICARE: USCG AIRSTA VENTURA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1100X	Military/U.S. Coast Guard Outpatient Clinic/Center

General Provider Information

NPI Number	:	1679451488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	USCG AIRSTA VENTURA

Provider Business Mailing Address
First Line	:	190 3RD STREET
Second Line	:
City	:	NAVAL AIR STATION POINT MUGU
State	:	CA
Zip	:	93042
Country	:	US
Telephone Number	:	805-874-3260
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 3RD STREET
Second Line	:
City	:	NAVAL AIR STATION POINT MUGU
State	:	CA
Zip	:	93042
Country	:	US
Telephone Number	:	805-874-3260
Fax Number	:

Authorized Official
Title or Position	:	HEALTH SERVICES ADMINISTRATOR
Name	:	RENEE R ESHAM
Credential	:	HS1
Telephone Number	:	805-502-9989

Provider Enumeration Date	:	08/21/2025
Last Update Date	:	08/21/2025

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