Basic Information
| Provider Information | |||||||||
| NPI: | 1285733436 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLIAM BEAUMONT ARMY MEDICAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BLISS MAIN OP PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 18511 HIGHLANDER MEDICS ST | ||||||||
| Address2: | |||||||||
| City: | FORT BLISS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799065327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155693367 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18511 HIGHLANDER MEDICS ST | ||||||||
| Address2: | |||||||||
| City: | FORT BLISS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155692170 | ||||||||
| FaxNumber: | 9155691556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | NATIVIDAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MSAO | ||||||||
| AuthorizedOfficialTelephone: | 9155693367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2093297 | 01 | PK | OTHER |