Provider Demographics
NPI:1720018757
Name:MEDDAC-WACH
Entity Type:Organization
Organization Name:MEDDAC-WACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:MARITSA
Authorized Official - Middle Name:
Authorized Official - Last Name:IRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-380-7343
Mailing Address - Street 1:5092 SUPERIOR VALLEY CT # B
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-2046
Mailing Address - Country:US
Mailing Address - Phone:760-386-8320
Mailing Address - Fax:
Practice Address - Street 1:5092 SUPERIOR VALLEY CT # B
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-2046
Practice Address - Country:US
Practice Address - Phone:760-386-8320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5167255286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital