Provider Demographics
NPI:1811134737
Name:121 COMBAT SUPPORT HOSPITAL
Entity type:Organization
Organization Name:121 COMBAT SUPPORT HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:VAUN
Authorized Official - Last Name:PLESHAW
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:2537-375-7777
Mailing Address - Street 1:121 COMBAT SUPPORT HOSPITAL
Mailing Address - Street 2:BOX 270
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121ST COMBAT SUPPORT HOSPITAL
Practice Address - Street 2:BOX 270
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-5281
Practice Address - Country:US
Practice Address - Phone:253-737-5777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP00056916302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization