Provider Demographics
NPI:1003998295
Name:U.S. COAST GUARD GROUP/AIR STATION HUMBOLDT BAY CLINIC
Entity Type:Organization
Organization Name:U.S. COAST GUARD GROUP/AIR STATION HUMBOLDT BAY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:CABUNOC
Authorized Official - Last Name:CAPACITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-839-6176
Mailing Address - Street 1:1001 LYCOMING AVE
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-9308
Mailing Address - Country:US
Mailing Address - Phone:707-839-6176
Mailing Address - Fax:
Practice Address - Street 1:1001 LYCOMING AVE
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-9308
Practice Address - Country:US
Practice Address - Phone:707-839-6176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center