Healthcare Provider Details

I. General information

NPI: 1548475619
Provider Name (Legal Business Name): 121ST CSH/BAACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 2097 CAMP WALKER
APO AP
96278
US

IV. Provider business mailing address

BOX 316 UNIT 15244
APO AP
96205
US

V. Phone/Fax

Practice location:
  • Phone: 01182279171410
  • Fax:
Mailing address:
  • Phone: 01182279171858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHONG MCCUE
Title or Position: CHIEF, UBO
Credential:
Phone: 01182279171857