MEDICARE: D CO 168TH MED BN BOX 36B APO AP 96218

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	261QM1102X	Military Outpatient Operational (Transportable) Component Clinic/Center

General Provider Information

NPI Number	:	1891853743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	D CO 168TH MED BN BOX 36B APO AP 96218

Provider Business Mailing Address
First Line	:	D CO 168TH MED BN UNIT 15021
Second Line	:
City	:	APO
State	:	AP
Zip	:	96218
Country	:	KR
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	D CO 168TH MED BN UNIT 15021 BOX 36B
Second Line	:
City	:	APO
State	:	AP
Zip	:	96218
Country	:	KR
Telephone Number	:	314-764-5272
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN ASSISTANT
Name	:	MS. DEJUANA L. RIAT
Credential	:	PA-C
Telephone Number	:	134-737-5272

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	08/22/2020

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