Basic Information
| Provider Information | |||||||||
| NPI: | 1700092509 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IRELAND ARMY COMMUNITY HOSPITAL | ||||||||
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| OtherOrganizationName: | OCCUPATIONAL HLTH CLINIC-FT. MCCOY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 289 IRELAND AVE | ||||||||
| Address2: | ATTN: TREASURERS OFFICE | ||||||||
| City: | FORT KNOX | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401215111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026249274 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1679 S 10TH AVE | ||||||||
| Address2: | MCCOY OHC | ||||||||
| City: | FORT MCCOY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546565114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083883209 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | HORNBACK | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5026249870 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IRELAND ARMY COMMUNITY HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
ID Information
| ID | Type | State | Issuer | Description | 1891899274 | 01 | PARENT FACILITY IRELAND ACH NPI | OTHER |