Healthcare Provider Details

I. General information

NPI: 1053517003
Provider Name (Legal Business Name): NAVAL BRANCH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BATTLE GROUP WAY
WALLOPS ISLAND VA
23337-2229
US

IV. Provider business mailing address

8901 WISCONSIN AVE PSC BOX 509 CODE 6300
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 757-824-2130
  • Fax:
Mailing address:
  • Phone: 301-295-4934
  • Fax: 301-295-1299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1102X
TaxonomyMilitary Outpatient Operational (Transportable) Component Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCIA DICKSON
Title or Position: SUPERVISOR REVENUE COLLECTIION
Credential:
Phone: 757-824-2130