Provider Demographics
NPI:1891854014
Name:KENNER ARMY HEALTH CLINIC
Entity Type:Organization
Organization Name:KENNER ARMY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NCOIC PAD
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ-ROSADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-734-9299
Mailing Address - Street 1:700 24TH ST
Mailing Address - Street 2:ATTN PAD
Mailing Address - City:FORT LEE
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-9306
Mailing Address - Fax:
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:804-734-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
AN2598588OtherMEDCO
48-34289OtherNCPDP
AN2598588OtherMEDCO
OTH000Medicare UPIN