Healthcare Provider Details

I. General information

NPI: 1417185935
Provider Name (Legal Business Name): HQ AIR FORCE RESERVE COMMAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 PAGE RD
ROBINS AFB GA
31098-1601
US

IV. Provider business mailing address

135 PAGE RD
ROBINS AFB GA
31098-1601
US

V. Phone/Fax

Practice location:
  • Phone: 478-327-1893
  • Fax:
Mailing address:
  • Phone: 478-327-1893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN ALTON HARRISON
Title or Position: COMMAND FUNCTIONAL MANAGER
Credential: IDMT
Phone: 478-327-1893