Healthcare Provider Details

I. General information

NPI: 1912158445
Provider Name (Legal Business Name): MUNSON ARMY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 POPE AVE
FORT LEAVENWORTH KS
66027-2332
US

IV. Provider business mailing address

550 POPE AVE
FORT LEAVENWORTH KS
66027-2332
US

V. Phone/Fax

Practice location:
  • Phone: 931-684-6473
  • Fax:
Mailing address:
  • Phone: 931-684-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number22525123
License Number StatePA

VIII. Authorized Official

Name: EDITH COTTON
Title or Position: CREDENTIALS MANAGER
Credential:
Phone: 913-684-6562