Healthcare Provider Details

I. General information

NPI: 1467538371
Provider Name (Legal Business Name): USCG HEADQUARTERS SUPPORT COMMAND (K)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COMDT 2100 2ND ST SW CG-1122, SUITE 5314
WASHINGTON DC
20593-0001
US

IV. Provider business mailing address

COMDT 2100 2ND ST SW CG-1122, SUITE 5314
WASHINGTON DC
20593-0001
US

V. Phone/Fax

Practice location:
  • Phone: 202-372-4103
  • Fax: 202-372-4912
Mailing address:
  • Phone: 202-372-4103
  • Fax: 202-372-4912

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: JILLYNDA A. WILLIAMS
Title or Position: CLINIC SUPERVISOR
Credential:
Phone: 202-372-4103