Healthcare Provider Details

I. General information

NPI: 1508174434
Provider Name (Legal Business Name): USA MEDDAC-J
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USAG-J, BOX 3257
APO AP
96338-3257
US

IV. Provider business mailing address

UNIT 45011
APO AP
96338-5011
US

V. Phone/Fax

Practice location:
  • Phone: 315-263-7164
  • Fax:
Mailing address:
  • Phone: 315-263-4127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License NumberR017398
License Number StateSD

VIII. Authorized Official

Name: MR. GARY LEE LARSON
Title or Position: SUPERVISOR, CLINICAL NURSE
Credential: RN
Phone: 315-263-4016