Provider Demographics
NPI:1801837398
Name:62 MEDICAL GROUP
Entity Type:Organization
Organization Name:62 MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TESSIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-982-9918
Mailing Address - Street 1:690 BARNES BLVD
Mailing Address - Street 2:ATTN: SGHC
Mailing Address - City:MCCHORD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:98438
Mailing Address - Country:US
Mailing Address - Phone:253-982-9918
Mailing Address - Fax:253-982-0283
Practice Address - Street 1:690 BARNES BLVD
Practice Address - Street 2:ATTN: SGHC
Practice Address - City:MCCHORD AFB
Practice Address - State:WA
Practice Address - Zip Code:98438
Practice Address - Country:US
Practice Address - Phone:253-982-9918
Practice Address - Fax:253-982-0283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care