Provider Demographics
NPI:1508174434
Name:USA MEDDAC-J
Entity Type:Organization
Organization Name:USA MEDDAC-J
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR, CLINICAL NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:315-263-4016
Mailing Address - Street 1:UNIT 45011
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96338-5011
Mailing Address - Country:US
Mailing Address - Phone:315-263-4127
Mailing Address - Fax:
Practice Address - Street 1:USAG-J, BOX 3257
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96338-3257
Practice Address - Country:US
Practice Address - Phone:315-263-7164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR017398261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility