Healthcare Provider Details

I. General information

NPI: 1912100983
Provider Name (Legal Business Name): BRANCH MEDICAL CLINIC EDSON RANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STUART MESA RD, BLDG 310514 BOX 555191
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

PO BOX 555191 FIN MGMT CODE 0814
CAMP PENDLETON CA
92055-5191
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1621
  • Fax: 760-725-1661
Mailing address:
  • Phone: 760-725-1621
  • Fax: 760-725-1661

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: WILLIAM M CONDON
Title or Position: BUMED UBO
Credential:
Phone: 240-401-3643