Healthcare Provider Details

I. General information

NPI: 1376633693
Provider Name (Legal Business Name): USAMEDDAC BAVARIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 464 BOX 638
APO AE
09226
DE

IV. Provider business mailing address

CMR 464 BOX 638
APO AE
09226
DE

V. Phone/Fax

Practice location:
  • Phone: 011499721966378
  • Fax:
Mailing address:
  • Phone: 011499721966378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number2037311
License Number StateKY

VIII. Authorized Official

Name: MRS. JEANNETTE ROCHELLE DICKERSON
Title or Position: IMMUNIZATION NURSE
Credential: LPN
Phone: 011499721966378