Healthcare Provider Details

I. General information

NPI: 1215218342
Provider Name (Legal Business Name): KENNER ARMY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8204 AVE C
FORT LEE VA
23801-1716
US

IV. Provider business mailing address

700 24TH ST ATTN PAD
FORT LEE VA
23801-1716
US

V. Phone/Fax

Practice location:
  • Phone: 804-734-9000
  • Fax:
Mailing address:
  • Phone: 804-734-9306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CARLOS RODRIGUEZ-ROSADO
Title or Position: NCOIC PAD
Credential:
Phone: 804-734-9299