Provider Demographics
NPI:1316385628
Name:TRAVIS AF BASE
Entity Type:Organization
Organization Name:TRAVIS AF BASE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRANSITIONALYR PROGRAM COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-423-7182
Mailing Address - Street 1:19728 SE 35TH WAY
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-8855
Mailing Address - Country:US
Mailing Address - Phone:240-888-5977
Mailing Address - Fax:
Practice Address - Street 1:19728 SE 35TH WAY
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-8855
Practice Address - Country:US
Practice Address - Phone:240-888-5977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-08
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital