Provider Demographics
NPI:1003051210
Name:US ARMY
Entity type:Organization
Organization Name:US ARMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BRACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:APA-C
Authorized Official - Phone:910-988-6117
Mailing Address - Street 1:5587 LOCKRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-0240
Mailing Address - Country:US
Mailing Address - Phone:910-988-6117
Mailing Address - Fax:
Practice Address - Street 1:5587 LOCKRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311
Practice Address - Country:US
Practice Address - Phone:910-988-6117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01314261QM1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient