MEDICARE: UNITED STATES AIR FORCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	286500000X	Military Hospital

General Provider Information

NPI Number	:	1275843732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNITED STATES AIR FORCE

Provider Business Mailing Address
First Line	:	10333 CAMINO RUIZ APT 39
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-3284
Country	:	US
Telephone Number	:	858-837-3510
Fax Number	:

Provider Business Practice Location Address
First Line	:	11075 SANTA MONICA BLVD STE 300
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-7540
Country	:	US
Telephone Number	:	310-481-5089
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST (STUDENT)
Name	:	SARAH EMMA THOMPSON
Credential	:	M.A.
Telephone Number	:	310-481-5089

Provider Enumeration Date	:	10/18/2010
Last Update Date	:	10/18/2010

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Directions to “UNITED STATES AIR FORCE ” Practice Location

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