Provider Demographics
NPI:1568857357
Name:UNITED STATES ARMY
Entity Type:Organization
Organization Name:UNITED STATES ARMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENCY DIRECTOR OF TRAINING
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:I
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:808-433-6340
Mailing Address - Street 1:91-1030 KAILEOLEA DR
Mailing Address - Street 2:E3
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-6051
Mailing Address - Country:US
Mailing Address - Phone:806-778-3897
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER ARMY MEDICAL CENTER
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-6060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY563261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)