1871709576 NPI number — KIMBROUGH ACC MILITARY MTF

Table of content: (NPI 1871709576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871709576 NPI number — KIMBROUGH ACC MILITARY MTF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBROUGH ACC MILITARY MTF
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:
1871709576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2480 LLEWELLYN AVE
Provider Second Line Business Mailing Address:
CDR USAMEDDAC MCXR-BD STE 5800
Provider Business Mailing Address City Name:
FORT GEORGE G MEADE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20755-7081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-677-8253
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 G STREET
Provider Second Line Business Practice Location Address:
BLDG 400
Provider Business Practice Location Address City Name:
NEW CUMBERLAND
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-245-4018
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIMBROW
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
UBO MANAGER
Authorized Official Telephone Number:
301-677-8512

Provider Taxonomy Codes

  • Taxonomy code: 261QM1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1164507703 . This is a "PARENT FACILITY NPI" identifier . This identifiers is of the category "OTHER".




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