Basic Information
| Provider Information | |||||||||
| NPI: | 1487907234 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GUAM GERIATRICS CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 633 GOV CARLOS G CAMACHO RD | ||||||||
| Address2: | STE. 205 | ||||||||
| City: | TAMUNING | ||||||||
| State: | GU | ||||||||
| PostalCode: | 969133194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6716497232 | ||||||||
| FaxNumber: | 6716497233 | ||||||||
| Practice Location | |||||||||
| Address1: | 633 GOV CARLOS G CAMACHO RD | ||||||||
| Address2: | STE. 205 | ||||||||
| City: | TAMUNING | ||||||||
| State: | GU | ||||||||
| PostalCode: | 969133194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6716497232 | ||||||||
| FaxNumber: | 6716497233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | UNTALAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE ANN | ||||||||
| AuthorizedOfficialMiddleName: | MANIBUSAN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 6716497232 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | M-1360 | GU | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1063517639 | 01 | GU | PROVIDER NPI | OTHER |