Provider Demographics
NPI:1467644625
Name:TRICARE OUTPATIENT CLINIC CHULA VISTA
Entity Type:Organization
Organization Name:TRICARE OUTPATIENT CLINIC CHULA VISTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NAVY MEDICINE UBO PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:34520 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-2098
Mailing Address - Country:US
Mailing Address - Phone:619-532-6636
Mailing Address - Fax:619-532-6645
Practice Address - Street 1:644 NAPLES ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1636
Practice Address - Country:US
Practice Address - Phone:619-744-5354
Practice Address - Fax:619-744-5391
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL MEDICAL CENTER SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-13
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient