Healthcare Provider Details

I. General information

NPI: 1114975513
Provider Name (Legal Business Name): WEED ARMY COMMUNITY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 170
FORT IRWIN CA
92310
US

IV. Provider business mailing address

15752 SCOTT DR
FONTANA CA
92336-5046
US

V. Phone/Fax

Practice location:
  • Phone: 760-380-5183
  • Fax:
Mailing address:
  • Phone: 951-235-6329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number481436
License Number StateCA

VIII. Authorized Official

Name: MS. VICTORIA REGINA DAVIS
Title or Position: HEAD NURSE
Credential: RN
Phone: 760-380-5183