1073612024 NPI number — 61ST MEDICAL SQUADRON SGSR

Table of content: (NPI 1073612024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073612024 NPI number — 61ST MEDICAL SQUADRON SGSR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
61ST MEDICAL SQUADRON SGSR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073612024
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
483 N AVIATION BLDG
Provider Second Line Business Mailing Address:
BLDG 210
Provider Business Mailing Address City Name:
EL SEGUNDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90245-2808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-653-2378
Provider Business Mailing Address Fax Number:
310-363-1977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
483 N AVIATION BLVD BLDG 210
Provider Second Line Business Practice Location Address:
BLDG 210
Provider Business Practice Location Address City Name:
EL SEGUNDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90245-2808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-653-2378
Provider Business Practice Location Address Fax Number:
310-363-1977
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORALES
Authorized Official First Name:
HECTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF DHA PASS
Authorized Official Telephone Number:
210-536-6650

Provider Taxonomy Codes

  • Taxonomy code: 332000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2066006 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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