Healthcare Provider Details

I. General information

NPI: 1922206853
Provider Name (Legal Business Name): TRICARE OUTPATIENT CLINIC CLAIREMONT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8808 BALBOA AVE
SAN DIEGO CA
92123-1592
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 619-645-0169
  • Fax: 619-645-0193
Mailing address:
  • Phone: 619-645-0169
  • 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