Healthcare Provider Details

I. General information

NPI: 1770645194
Provider Name (Legal Business Name): 99TH MEDICAL GROUP - MIKE O'CALLAGHAN FEDERAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DUFFER DR BLDG 625
NELLIS AFB NV
89191
US

IV. Provider business mailing address

99 MDSS/SGSR 4700 N LAS VEGAS BLVD ATTN: THIRD PARTY BILLING
NELLIS AFB NV
89191
US

V. Phone/Fax

Practice location:
  • Phone: 702-652-6011
  • Fax: 702-653-2962
Mailing address:
  • Phone: 702-653-3589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: CHIEF DHA PASS
Credential:
Phone: 210-536-6650