Healthcare Provider Details

I. General information

NPI: 1215099189
Provider Name (Legal Business Name): 92 MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 HOSPITAL LOOP SUITE 135
FAIRCHILD AFB WA
99011-8704
US

IV. Provider business mailing address

92ND MEDICAL GROUP RMO OFFICE 3RD PARTY COLLECTIONS 701 HOSPITAL LOOP
FAIRCHILD AFB WA
99011-8704
US

V. Phone/Fax

Practice location:
  • Phone: 509-247-5567
  • Fax: 509-247-2021
Mailing address:
  • Phone: 509-247-5567
  • Fax: 509-247-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: CHIEF DHA PASS
Credential:
Phone: 210-536-6650