Healthcare Provider Details

I. General information

NPI: 1336283381
Provider Name (Legal Business Name): HMEDDAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USAG HESSEN, CMR 470, BOX 4429
APO AE
09165
DE

IV. Provider business mailing address

USAG HESSEN, CMR 470, BOX 4429
APO AE
09165
DE

V. Phone/Fax

Practice location:
  • Phone: 314-328-6709
  • Fax: 3286608
Mailing address:
  • Phone: 314-328-6709
  • Fax: 3286608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number39086
License Number StateHI

VIII. Authorized Official

Name: MS. CLUNIE M. JOHNSON
Title or Position: REGISTERED NURSE
Credential:
Phone: 314-328-6709