Healthcare Provider Details

I. General information

NPI: 1104153279
Provider Name (Legal Business Name): US COAST GUARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USCGC MORGENTHAU
FPO AP
96672-3916
US

IV. Provider business mailing address

91-1035 KAI LOLI STREET
EWA BEACH HI
96706
US

V. Phone/Fax

Practice location:
  • Phone: 501-437-3981
  • Fax:
Mailing address:
  • Phone: 501-437-3981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2008333
License Number StateCA

VIII. Authorized Official

Name: DR. NIDHI JAIN,
Title or Position: CDR
Credential: M.D
Phone: 510-437-3688