Healthcare Provider Details

I. General information

NPI: 1952854648
Provider Name (Legal Business Name): US ARMY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 2669 WEST REGIMENTAL ROAD
FT MCCOY WI
54656-5229
US

IV. Provider business mailing address

BLDG 2669 WEST REGIMENTAL ROAD
FT MCCOY WI
54656-5229
US

V. Phone/Fax

Practice location:
  • Phone: 608-388-3025
  • Fax: 608-388-4818
Mailing address:
  • Phone: 608-388-3025
  • Fax: 608-388-4818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number343143
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number70101705
License Number StateWI

VIII. Authorized Official

Name: MR. JESSE C KOLLASCH-ROBERTS
Title or Position: NURSE ASSISTANT
Credential:
Phone: 608-388-3025