Healthcare Provider Details

I. General information

NPI: 1649366980
Provider Name (Legal Business Name): UNITED STATES COAST GUARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 URBANNA CREEK CT
SALUDA VA
23149-3075
US

IV. Provider business mailing address

30 URBANNA CREEK CT
SALUDA VA
23149-3075
US

V. Phone/Fax

Practice location:
  • Phone: 804-758-1631
  • Fax:
Mailing address:
  • Phone: 804-758-1631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number24720000X
License Number StateVA

VIII. Authorized Official

Name: MR. KENNETH RAY MITCHELL JR.
Title or Position: HEALTH SERVICE TECHNICIAN
Credential: M.A.
Phone: 757-856-2230