Healthcare Provider Details

I. General information

NPI: 1609269307
Provider Name (Legal Business Name): DEPARTMENT OF DEFENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 STUART ST
COLUMBIA SC
29207-5700
US

IV. Provider business mailing address

2000 N BELTLINE BLVD APT 313
COLUMBIA SC
29204-3942
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-2160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberF337835-1
License Number StateNY

VIII. Authorized Official

Name: MRS. JEAN M BARIDO
Title or Position: DEPUTY COMMANDER FOR NURSING
Credential: COL
Phone: 803-751-2119