Provider Demographics
NPI:1023212677
Name:BRANCH MEDICAL CLINIC CHINA LAKE
Entity Type:Organization
Organization Name:BRANCH MEDICAL CLINIC CHINA LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUMED UBO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:1 ADMINISTRATION CIR
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-6104
Mailing Address - Country:US
Mailing Address - Phone:760-830-2498
Mailing Address - Fax:760-830-2182
Practice Address - Street 1:1 ADMINISTRATION CIR
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-6104
Practice Address - Country:US
Practice Address - Phone:760-830-2498
Practice Address - Fax:760-830-2182
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HOSPITAL TWENTYNINE PALMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-14
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANOT REQUIREDOtherMAILHANDLERS BENEFIT PLAN
CA5662OtherBLUE CROSS BLUE SHIELD
CA5662OtherBLUE CROSS BLUE SHIELD