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General NPI Number Information
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NPI Number | 1669689568
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Entity Type | Organization
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Legal Business Name | UNITED STATES COAST GUARD
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 07/08/2008
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Provider Practice Location Address
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Address Line | 410 PENNSYLVANIA AVE # A
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City | PETALUMA
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State | CA
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Zip | 94952-9103
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Country | US
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Telephone | 707-971-9364
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Fax |
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Provider Business Mailing Address
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Address Line | 410 PENNSYLVANIA AVE # A
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City | PETALUMA
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State | CA
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Zip | 94952-9103
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINIC ADMINISTRATOR
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Name | TODD ALLEN DEVORE
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Credential |
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Telephone | 707-971-9364
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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 |
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License Number State |
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