Provider Demographics
NPI:1588654990
Name:DEPARTMENT OF DEFENSE
Entity Type:Organization
Organization Name:DEPARTMENT OF DEFENSE
Other - Org Name:UNITED STATES ARMY
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:703-576-1403
Mailing Address - Street 1:1949 POHICK CREEK CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2428
Mailing Address - Country:US
Mailing Address - Phone:703-492-9112
Mailing Address - Fax:
Practice Address - Street 1:14450 SMOKETOWN RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4712
Practice Address - Country:US
Practice Address - Phone:703-576-1397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904004811261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center