Basic Information
| Provider Information | |||||||||
| NPI: | 1801288634 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRANCH MEDICAL CLINIC NALF SAN CLEMENTE ISLAND | ||||||||
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| Mailing Information | |||||||||
| Address1: | WILSON COVE | ||||||||
| Address2: | BLDG 60126 | ||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195249356 | ||||||||
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| Practice Location | |||||||||
| Address1: | WILSON COVE | ||||||||
| Address2: | BLDG 60126 | ||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195249356 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2015 | ||||||||
| LastUpdateDate: | 11/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | CONDON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BUMED UBO | ||||||||
| AuthorizedOfficialTelephone: | 2404013643 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NAVAL MEDICAL CENTER SAN DIEGO | ||||||||
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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 |
No ID Information.