Basic Information
| Provider Information | |||||||||
| NPI: | 1134106131 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILSECK MEDICAL TREATMENT FACILITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | CMR 411, BOX 549 | ||||||||
| Address2: | |||||||||
| City: | APO | ||||||||
| State: | AE | ||||||||
| PostalCode: | 09112 | ||||||||
| CountryCode: | DE | ||||||||
| TelephoneNumber: | 01149966283 | ||||||||
| FaxNumber: | 3143 | ||||||||
| Practice Location | |||||||||
| Address1: | CMR 411, BOX 549 | ||||||||
| Address2: | |||||||||
| City: | APO | ||||||||
| State: | AE | ||||||||
| PostalCode: | 09112 | ||||||||
| CountryCode: | DE | ||||||||
| TelephoneNumber: | 01149966283 | ||||||||
| FaxNumber: | 3143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 0114993180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | SW111104 | MA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | SW111104 | 01 | MA | SOCIAL WORKER | OTHER |