Healthcare Provider Details

I. General information

NPI: 1215057641
Provider Name (Legal Business Name): DFASIN-ADIMB U.S. ARMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4501
US

IV. Provider business mailing address

8505 LEXINGTON DR
SEVERN MD
21144-2729
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-3249
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State

VIII. Authorized Official

Name: MRS. DOROTHY A. FLORES
Title or Position: CREDENTIALS COORDINATOR
Credential:
Phone: 210-916-5102