Basic Information
| Provider Information | |||||||||
| NPI: | 1932208352 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAPE COD USCG PHCY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAPE COD USCG PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | US COAST GUARD FINANCE CTR | ||||||||
| Address2: | 1430 KRISTINA WAY | ||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233260002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105366650 | ||||||||
| FaxNumber: | 2105366179 | ||||||||
| Practice Location | |||||||||
| Address1: | KAEHLER MEMORIAL MEDICAL CLINIC | ||||||||
| Address2: | 5201 LEE RD US AIR STATION | ||||||||
| City: | CAPE COD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089686702 | ||||||||
| FaxNumber: | 5089686620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 06/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 2039156 | 01 | PK | OTHER |