Provider Demographics
NPI:1336339415
Name:UNITED STATES COAST GUARD
Entity Type:Organization
Organization Name:UNITED STATES COAST GUARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HS3
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:619-992-5671
Mailing Address - Street 1:427 COMMERCIAL ST
Mailing Address - Street 2:CLINIC
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-1027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:427 COMMERCIAL ST
Practice Address - Street 2:CLINIC
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-1027
Practice Address - Country:US
Practice Address - Phone:619-992-5671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD4080169251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management