Provider Demographics
NPI:1083028989
Name:WEED ARMY COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:WEED ARMY COMMUNITY HOSPITAL
Other - Org Name:TBI CLINIC-IRWIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C, PAD
Authorized Official - Prefix:
Authorized Official - First Name:DERRECK
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-380-3392
Mailing Address - Street 1:4TH STREET
Mailing Address - Street 2:BLDG 166 RM 109
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-5109
Mailing Address - Country:US
Mailing Address - Phone:760-380-5213
Mailing Address - Fax:
Practice Address - Street 1:BLDG 189 AVE B
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-380-7473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEED ARMY COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-18
Last Update Date:2015-04-07
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
1275618514OtherPARENT FACILITY WACH NPI 2