Provider Demographics
NPI:1972706992
Name:BRANCH MEDICAL CLINIC CAMP PENDLETON
Entity Type:Organization
Organization Name:BRANCH MEDICAL CLINIC CAMP PENDLETON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUMED UBO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:PO BOX 555191
Mailing Address - Street 2:FIN MGMT CODE 0814
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5191
Mailing Address - Country:US
Mailing Address - Phone:760-725-1621
Mailing Address - Fax:760-725-1661
Practice Address - Street 1:BLDG 13129 14TH STREET
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5191
Practice Address - Country:US
Practice Address - Phone:760-725-1621
Practice Address - Fax:760-725-1661
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HOSPITAL CAMP PENDELTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-07
Last Update Date:2017-10-16
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
CA1386604387OtherPARENT FACILITY NPI