Provider Demographics
NPI:1265709240
Name:USAMEDDAC-K,FHP,OHS
Entity type:Organization
Organization Name:USAMEDDAC-K,FHP,OHS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL HEALTH NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KYOUNG
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOLTUC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-732-7396
Mailing Address - Street 1:629TH MEDICAL COMPANY
Mailing Address - Street 2:UNIT # 15342
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96258-5342
Mailing Address - Country:US
Mailing Address - Phone:315-732-7396
Mailing Address - Fax:
Practice Address - Street 1:629TH MEDICAL COMPANY
Practice Address - Street 2:UNIT # 15342
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96258-5342
Practice Address - Country:US
Practice Address - Phone:315-732-7396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403434286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital