Healthcare Provider Details

I. General information

NPI: 1174969331
Provider Name (Legal Business Name): GOVERNMENT OF GUAM DEPARTMENT OF ADMINISTRATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 CHALAN KARETA
MANGILAO GU
96913-6304
US

IV. Provider business mailing address

123 CHALAN KARETA
MANGILAO GU
96913-6304
US

V. Phone/Fax

Practice location:
  • Phone: 671-735-7111
  • Fax: 671-734-7097
Mailing address:
  • Phone: 671-735-7111
  • Fax: 671-734-7097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JAMES W GILLAN
Title or Position: DIRECTOR
Credential: MPH
Phone: 671-735-7101