Provider Demographics
NPI:1760550636
Name:121ST CSH/BAACH
Entity Type:Organization
Organization Name:121ST CSH/BAACH
Other - Org Name:ACH BRIAN ALLGOOD-SEOUL
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF, UBO
Authorized Official - Prefix:
Authorized Official - First Name:CHONG
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:0118227-917-1857
Mailing Address - Street 1:UNIT 15244 BOX 316
Mailing Address - Street 2:ATTN UBO
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5244
Mailing Address - Country:US
Mailing Address - Phone:0118227-917-1858
Mailing Address - Fax:
Practice Address - Street 1:UNIT 15244
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-5244
Practice Address - Country:US
Practice Address - Phone:0118227-917-1410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
Provider Identifiers
StateIdentifier IDID TypeIssuer
8210077OtherNCPDP
OTH000Medicare UPIN
VAD000Medicare UPIN