Provider Demographics
NPI:1689691230
Name:419 MEDICAL SQUADRON
Entity Type:Organization
Organization Name:419 MEDICAL SQUADRON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ATISME
Authorized Official - Suffix:
Authorized Official - Credentials:LISW, CSW
Authorized Official - Phone:801-777-2622
Mailing Address - Street 1:3626 W 2000 N
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:UT
Mailing Address - Zip Code:84015-7300
Mailing Address - Country:US
Mailing Address - Phone:801-776-8767
Mailing Address - Fax:
Practice Address - Street 1:7311 11TH ST
Practice Address - Street 2:
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-777-2622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06477276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit