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General NPI Number Information
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NPI Number | 1528142809
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Entity Type | Organization
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Legal Business Name | COAST GUARD
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Dates
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Enumeration Date | 10/24/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | COMDT CG-1122 2100 2ND ST SW SUITE 5314
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City | WASHINGTON
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State | DC
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Zip | 20593-0001
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Country | US
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Telephone | 508-968-6572
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Fax | 508-968-6581
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Provider Business Mailing Address
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Address Line | COMDT CG-1122 2100 2ND ST SW SUITE 5314
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City | WASHINGTON
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State | DC
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Zip | 20593-0001
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Country | US
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Telephone | 508-968-6572
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Fax | 508-968-6581
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Authorized Official
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Title or Position | SUPERVISOR
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Name | RICHARD A JACKSON
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Credential |
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Telephone | 508-968-6713
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1101X
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Taxonomy Name | Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
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License Number |
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License Number State |
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