Provider Demographics
NPI:1578541520
Name:USAMEDDAC FT EUSTIS VA
Entity Type:Organization
Organization Name:USAMEDDAC FT EUSTIS VA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARMY PUBLIC HEALTH NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:III
Authorized Official - Credentials:BSN
Authorized Official - Phone:757-878-4110
Mailing Address - Street 1:128 KENILWORTH DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4025
Mailing Address - Country:US
Mailing Address - Phone:757-223-0653
Mailing Address - Fax:
Practice Address - Street 1:BLDG 2792 HARRISON LOOP
Practice Address - Street 2:PREVENTIVE MEDICINE
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604
Practice Address - Country:US
Practice Address - Phone:757-878-4110
Practice Address - Fax:757-878-4533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN162229251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare