# UNITED STATES NAVY

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1386886489
- **Authorized official:** SHANE C HICKS IDC (INDEPENDENT DUTY CORPSMAN)
- **Authorized official phone:** (843) 574-8242

## Contact information

- **Practice address:** 3600 RIVERS AVE, CHARLESTON, WA 29405
- **Practice address phone:** (843) 574-8242
- **Mailing address:** 48 HICKORY HALL LN, GOOSE CREEK, SC 29445-6318
- **Mailing address phone:** (360) 689-9072

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM1103X | Military Ambulatory Procedure Visits Operational (Transportable) Clinic/Center | — | TX | Yes |

## Other

- **Enumeration date:** 04/03/2009
- **Last updated:** 07/21/2022