Healthcare Provider Details

I. General information

NPI: 1740377423
Provider Name (Legal Business Name): AMC WOMACK-FT BRAGG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 REILLY ST
FORT BRAGG NC
28310-7301
US

IV. Provider business mailing address

2817 REILLY ST MCXC-DBO-UB WAMC STOP A
FORT BRAGG NC
28310-7301
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-9262
  • Fax:
Mailing address:
  • Phone: 910-907-6693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code341800000X
TaxonomyMilitary/U.S. Coast Guard Transport,
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MARVIN PRIMOS
Title or Position: UBO MANAGER
Credential:
Phone: 910-907-8440