Provider Demographics
NPI:1114986932
Name:BRANCH MEDICAL CLINIC FT WORTH
Entity Type:Organization
Organization Name:BRANCH MEDICAL CLINIC FT WORTH
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 1:1711 DOOLITTLE AVE
Mailing Address - Street 2:
Mailing Address - City:NAVAL AIR STATION/ JRB
Mailing Address - State:TX
Mailing Address - Zip Code:76127-1133
Mailing Address - Country:US
Mailing Address - Phone:361-961-6079
Mailing Address - Fax:361-961-2611
Practice Address - Street 1:1711 DOOLITTLE AVE
Practice Address - Street 2:
Practice Address - City:NAVAL AIR STATION/ JRB
Practice Address - State:TX
Practice Address - Zip Code:76127
Practice Address - Country:US
Practice Address - Phone:361-961-6079
Practice Address - Fax:361-961-2611
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HEALTH CLINIC CORPUS CHRISTI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-21
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient