Basic Information
| Provider Information | |||||||||
| NPI: | 1376890293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIVIDUAL PROVIDER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 BOATNER ROAD SUITE 114 | ||||||||
| Address2: | 96TH MEDICAL GROUP | ||||||||
| City: | EGLIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508838600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 307 BOATNER ROAD SUITE 114 | ||||||||
| Address2: | 96TH MEDICAL GROUP | ||||||||
| City: | EGLIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508838600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 09/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | THAI | ||||||||
| AuthorizedOfficialFirstName: | CHUONG | ||||||||
| AuthorizedOfficialMiddleName: | NGUYEN | ||||||||
| AuthorizedOfficialTitleorPosition: | MAJOR | ||||||||
| AuthorizedOfficialTelephone: | 8508839055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | Y | Hospitals | Military Hospital |
No ID Information.