Provider Demographics
NPI:1437502325
Name:DEPARTMENT OF DEFENSE
Entity Type:Organization
Organization Name:DEPARTMENT OF DEFENSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ARIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-772-6214
Mailing Address - Street 1:11050 MT BEVLEDERE BLVD.
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AA
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:315-772-2778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARMY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1053724807261QM1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient