Healthcare Provider Details

I. General information

NPI: 1295724409
Provider Name (Legal Business Name): 18TH MEDCOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDCOM UNIT # 15281
APO AP
96205-0054
KR

IV. Provider business mailing address

121ST GENERAL HOSPITAL BOX 539
APO AP
96205-0017
KR

V. Phone/Fax

Practice location:
  • Phone: 315-736-3025
  • Fax: 315-736-3028
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number524305
License Number StateCA

VIII. Authorized Official

Name: MRS. HAN YI WOO
Title or Position: OCCUPATIONAL HEALTH NURSING SUPERVI
Credential: RN, COHN
Phone: 315-736-7565