Healthcare Provider Details

I. General information

NPI: 1265780936
Provider Name (Legal Business Name): NAVAL BRANCH HEALTH CLINIC NEW ENGLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WAHOO AVE
GROTON CT
06349-2324
US

IV. Provider business mailing address

PO BOX 600
GROTON CT
06349-5600
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-4725
  • Fax:
Mailing address:
  • Phone: 860-694-4725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberR170002
License Number StateMD

VIII. Authorized Official

Name: MR. MARK MAMMOTH
Title or Position: MEDICAL STAFF PROFESSIONAL SERVICES
Credential:
Phone: 860-694-2377