Healthcare Provider Details

I. General information

NPI: 1942384383
Provider Name (Legal Business Name): COMDT (CG-1122)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

U S COAST GUARD 2100 2ND ST SW STE 5314
WASHINGTON DC
20593-0001
US

IV. Provider business mailing address

U S COAST GUARD 2100 2ND ST SW STE 5314
WASHINGTON DC
20593-0001
US

V. Phone/Fax

Practice location:
  • Phone: 707-765-7200
  • Fax: 707-765-7521
Mailing address:
  • Phone: 707-765-7200
  • Fax: 707-765-7521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: DESIREE LORELEI DIAS
Title or Position: TECHNICIAN
Credential:
Phone: 707-765-7200