Provider Demographics
NPI:1073591830
Name:19TH MDSS SGSR
Entity Type:Organization
Organization Name:19TH MDSS SGSR
Other - Org Name:LITTLE ROCK AFB MTF
Other - Org Type:Other Name
Authorized Official - Title/Position:AIR FORCE UBO ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-681-7613
Mailing Address - Street 1:1090 ARNOLD DR
Mailing Address - Street 2:
Mailing Address - City:LR AFB
Mailing Address - State:AR
Mailing Address - Zip Code:72099-4933
Mailing Address - Country:US
Mailing Address - Phone:501-987-7414
Mailing Address - Fax:501-987-7310
Practice Address - Street 1:1090 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:LR AFB
Practice Address - State:AR
Practice Address - Zip Code:72099-4933
Practice Address - Country:US
Practice Address - Phone:501-987-7414
Practice Address - Fax:501-987-7310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR420846OtherNCPDP