Healthcare Provider Details

I. General information

NPI: 1306046727
Provider Name (Legal Business Name): BRANCH MEDICAL CLINIC IWAKUNI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 561 BOX 1877
FPO AP
96310
JP

IV. Provider business mailing address

PSC 561 BOX 1877
FPO AP
96310
JP

V. Phone/Fax

Practice location:
  • Phone: 01181468168574
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM MICHAEL CONDON
Title or Position: NAVY MEDICINE UBO PROGRAM MANAGER
Credential:
Phone: 240-401-3643