Healthcare Provider Details

I. General information

NPI: 1407012610
Provider Name (Legal Business Name): NAVY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 WINDSOR LAKE DR
LOUISA VA
23093-2135
US

IV. Provider business mailing address

PSC 807 BOX 33
FPO AE
09729-0002
US

V. Phone/Fax

Practice location:
  • Phone: 804-457-4105
  • 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: CHRISTOPHER CRUMPLER
Title or Position: IDC MANAGER
Credential:
Phone: 804-457-4105