Provider Demographics
NPI:1043426893
Name:121ST CSH/BAACH
Entity Type:Organization
Organization Name:121ST CSH/BAACH
Other - Org Name:AHC CAMP CASEY-TONGDUCHON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF, UBO
Authorized Official - Prefix:
Authorized Official - First Name:CHONG
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:0118227-917-1857
Mailing Address - Street 1:UNIT 15244 BOX 316
Mailing Address - Street 2:ATTN UBO
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5244
Mailing Address - Country:US
Mailing Address - Phone:0118227-917-1858
Mailing Address - Fax:
Practice Address - Street 1:UNIT 15543
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96224
Practice Address - Country:US
Practice Address - Phone:0118227-917-1410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:121ST CSH/BAACH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2015-11-18
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
1760550636OtherPARENT FACILITY NPI
8210091OtherPHARMACY NCPDP
OTH000Medicare UPIN
VAD000Medicare UPIN