Healthcare Provider Details

I. General information

NPI: 1225220270
Provider Name (Legal Business Name): BRANCH MEDICAL CLINIC CORONADO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 MCCAIN BLVD NAVAL BASE CORONADO
SAN DIEGO CA
92135-7046
US

IV. Provider business mailing address

NAVAL BASE CORONADO BLD 601 MCCAIN BLVD BRANCH MEDICAL CLINIC
SAN DIEGO CA
92135
US

V. Phone/Fax

Practice location:
  • Phone: 619-545-7245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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