Basic Information
| Provider Information | |||||||||
| NPI: | 1023117462 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 99TH MEDICAL GROUP - MIKE O'CALLAGHAN FEDERAL HOSPITAL | ||||||||
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| OtherOrganizationName: | NELLIS BRAVO PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 MDSS/SGSR 4700 N LAS VEGAS BLVD | ||||||||
| Address2: | ATTN: THRID PARTY BILLING | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026533589 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4700 LAS VEGAS BLVD N | ||||||||
| Address2: | BLDG 1300 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891916600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026533205 | ||||||||
| FaxNumber: | 7026532106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 01/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2051375 | 01 | PK | OTHER |