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General NPI Number Information
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NPI Number | 1003051210
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Entity Type | Organization
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Legal Business Name | US ARMY
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Dates
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Enumeration Date | 12/03/2008
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Last Update Date | 12/03/2008
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Provider Practice Location Address
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Address Line | 5587 LOCKRIDGE ROAD
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City | FAYETTEVILLE
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State | NC
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Zip | 28311
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Country | US
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Telephone | 910-988-6117
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Fax |
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Provider Business Mailing Address
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Address Line | 5587 LOCKRIDGE RD
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City | FAYETTEVILLE
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State | NC
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Zip | 28311-0240
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Country | US
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Telephone | 910-988-6117
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Fax |
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Authorized Official
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Title or Position | PA
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Name | CHRISTOPHER SCOTT BRACKMAN
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Credential | APA-C
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Telephone | 910-988-6117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1100X
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Taxonomy Name | Military/U.S. Coast Guard Outpatient Clinic/Center
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License Number | 0010-01314
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License Number State | NC
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