Provider Demographics
NPI:1952854648
Name:US ARMY HEALTH CLINIC
Entity Type:Organization
Organization Name:US ARMY HEALTH CLINIC
Other - Org Name:IRELAND ARMY COMMUNITY HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:NURSE ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOLLASCH-ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-388-3025
Mailing Address - Street 1:BLDG 2669 WEST REGIMENTAL ROAD
Mailing Address - Street 2:
Mailing Address - City:FT MCCOY
Mailing Address - State:WI
Mailing Address - Zip Code:54656-5229
Mailing Address - Country:US
Mailing Address - Phone:608-388-3025
Mailing Address - Fax:608-388-4818
Practice Address - Street 1:BLDG 2669 WEST REGIMENTAL ROAD
Practice Address - Street 2:
Practice Address - City:FT MCCOY
Practice Address - State:WI
Practice Address - Zip Code:54656-5229
Practice Address - Country:US
Practice Address - Phone:608-388-3025
Practice Address - Fax:608-388-4818
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNITED STATES ARMY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI343143261QM1100X
WI70101705261QM1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure