Healthcare Provider Details

I. General information

NPI: 1316385628
Provider Name (Legal Business Name): TRAVIS AF BASE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2013
Last Update Date: 06/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19728 SE 35TH WAY
CAMAS WA
98607-8855
US

IV. Provider business mailing address

19728 SE 35TH WAY
CAMAS WA
98607-8855
US

V. Phone/Fax

Practice location:
  • Phone: 240-888-5977
  • Fax:
Mailing address:
  • Phone: 240-888-5977
  • 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: STEPHANIE MANNEL
Title or Position: TRANSITIONALYR PROGRAM COORDINATOR
Credential:
Phone: 707-423-7182