Healthcare Provider Details

I. General information

NPI: 1932460086
Provider Name (Legal Business Name): USN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 CHARTER OAK DR
GROTON CT
06340-2908
US

IV. Provider business mailing address

159 CHARTER OAK DR
GROTON CT
06340-2908
US

V. Phone/Fax

Practice location:
  • Phone: 904-214-6030
  • Fax:
Mailing address:
  • Phone: 904-214-6030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State

VIII. Authorized Official

Name: SUSANO MICHEL SILVA
Title or Position: SUBMARINE
Credential: IDC
Phone: 904-214-6030