Basic Information
| Provider Information | |||||||||
| NPI: | 1922206853 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRICARE OUTPATIENT CLINIC CLAIREMONT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34800 BOB WILSON DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921341098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196450169 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8808 BALBOA AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196450169 | ||||||||
| FaxNumber: | 6196450193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | CONDON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | NAVY MEDICINE UBO PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2404013643 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NAVAL MEDICAL CENTER SAN DIEGO | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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.