Basic Information
| Provider Information | |||||||||
| NPI: | 1609289362 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOD FT LEONARD WOOD EPHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL | ||||||||
| Address2: | CO MCXP RMD BB 126 MISSOURI AVENUE | ||||||||
| City: | FT. LEONARD WOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654738952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735961709 | ||||||||
| FaxNumber: | 5735960405 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 MISSOURI AVE | ||||||||
| Address2: | GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL | ||||||||
| City: | FORT LEONARD WOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654738952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735961709 | ||||||||
| FaxNumber: | 5735960405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2014 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| 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 | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2146212 | 01 | PK | OTHER |