Healthcare Provider Details

I. General information

NPI: 1730386327
Provider Name (Legal Business Name): BRANCH MEDICAL CLINIC NTC SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 CUSHING ROAD BLDG 624
SAN DIEGO CA
92106-0000
US

IV. Provider business mailing address

2051 CUSHING ROAD BLDG 624
SAN DIEGO CA
92106-0000
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-0173
  • Fax: 619-524-0118
Mailing address:
  • Phone: 619-524-0173
  • Fax: 619-524-0118

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