MEDICARE: 419 MEDICAL SQUADRON

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	276400000X	Substance Use Disorder Rehabilitation Hospital Unit	06477	IA

General Provider Information

NPI Number	:	1689691230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	419 MEDICAL SQUADRON

Provider Business Mailing Address
First Line	:	3626 W 2000 N
Second Line	:
City	:	WEST POINT
State	:	UT
Zip	:	84015-7300
Country	:	US
Telephone Number	:	801-776-8767
Fax Number	:

Provider Business Practice Location Address
First Line	:	7311 11TH ST
Second Line	:
City	:	HILL AFB
State	:	UT
Zip	:	84056-5012
Country	:	US
Telephone Number	:	801-777-2622
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH THERAPIST
Name	:	MR. ROBERT ATISME
Credential	:	LISW, CSW
Telephone Number	:	801-777-2622

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	06/13/2008

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1447244652 — TRACY WINGERT
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1841284056 — MRS. JEANINE GAIL STETTLER PNP
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1295721603 — DR. PAUL E LEWIS III MD, MPH
Practice Location Address:

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1639166416 — DR. DELLRAY H ANDERSON M.D.
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1538157540 — MR. MATTHEW M YATES PA-C
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