Healthcare Provider Details

I. General information

NPI: 1679824585
Provider Name (Legal Business Name): UNITED STATES NAVY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 14137
CAMP PENDLETON CA
92055-5697
US

IV. Provider business mailing address

PO BOX 555697 COMBAT LOGISTICS BATTALION 11
CAMP PENDLETON CA
92055-5697
US

V. Phone/Fax

Practice location:
  • Phone: 760-763-4028
  • Fax:
Mailing address:
  • Phone: 760-763-4028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number1096852
License Number StatePA

VIII. Authorized Official

Name: MS. CHELSEA LAUREN MCLEAN
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C, M.H.S
Phone: 434-960-2638