Healthcare Provider Details

I. General information

NPI: 1700117538
Provider Name (Legal Business Name): LBJ MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX LBJ
PAGO PAGO AMERICAN SAMOA
96799
UM

IV. Provider business mailing address

PO BOX LBJ
PAGO PAGO AS
96799-0010
US

V. Phone/Fax

Practice location:
  • Phone: 684-633-1222
  • Fax:
Mailing address:
  • Phone: 684-633-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number1097-A
License Number StateAS

VIII. Authorized Official

Name: MRS. PATRICIA TINDALL
Title or Position: CEO
Credential:
Phone: 684-633-1222