Healthcare Provider Details

I. General information

NPI: 1528167582
Provider Name (Legal Business Name): 60TH MEDICAL GROUP SGSL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR RM 1C409
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR RM 1C409
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7114
  • Fax: 707-423-7994
Mailing address:
  • Phone: 707-423-7114
  • Fax: 707-423-7994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: CHIEF DHA PASS
Credential:
Phone: 210-536-6650