1083012223 NPI number — 96TH MEDICAL SUPPORT SQUADRON

Table of content: (NPI 1083012223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083012223 NPI number — 96TH MEDICAL SUPPORT SQUADRON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
96TH MEDICAL SUPPORT SQUADRON
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:
1083012223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 BOATNER RD STE 114
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EGLIN AFB
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32542-1302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-885-7554
Provider Business Mailing Address Fax Number:
850-885-9977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4315 EL SALVADOR WAY
Provider Second Line Business Practice Location Address:
BUILDING 4315
Provider Business Practice Location Address City Name:
EGLIN AFB
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32542-1711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-885-7554
Provider Business Practice Location Address Fax Number:
850-885-9977
Provider Enumeration Date:
12/19/2014

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: 2149365 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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