Provider Demographics
NPI:1265780936
Name:NAVAL BRANCH HEALTH CLINIC NEW ENGLAND
Entity type:Organization
Organization Name:NAVAL BRANCH HEALTH CLINIC NEW ENGLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF PROFESSIONAL SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMMOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-694-2377
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5600
Mailing Address - Country:US
Mailing Address - Phone:860-694-4725
Mailing Address - Fax:
Practice Address - Street 1:1 WAHOO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-2324
Practice Address - Country:US
Practice Address - Phone:860-694-4725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR170002261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service