# COAST GUARD

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

## Provider details

- **NPI number:** 1528142809
- **Authorized official:** RICHARD A JACKSON (SUPERVISOR)
- **Authorized official phone:** (508) 968-6713

## Contact information

- **Practice address:** COMDT CG-1122 2100 2ND ST SW, SUITE 5314, WASHINGTON, DC 20593-0001
- **Practice address phone:** (508) 968-6572
- **Practice address fax:** (508) 968-6581
- **Mailing address:** COMDT CG-1122 2100 2ND ST SW, SUITE 5314, WASHINGTON, DC 20593-0001
- **Mailing address phone:** (508) 968-6572
- **Mailing address fax:** (508) 968-6581

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM1101X | Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 10/24/2006
- **Last updated:** 08/22/2020