Organization
COAST GUARD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RICHARD A JACKSON (SUPERVISOR)
(508) 968-6713
Entity
Organization
Contact information
Practice address
COMDT CG-1122 2100 2ND ST SW, SUITE 5314, WASHINGTON, DC 20593-0001
(508) 968-6572
(508) 968-6581
Mailing address
COMDT CG-1122 2100 2ND ST SW, SUITE 5314, WASHINGTON, DC 20593-0001
(508) 968-6572
(508) 968-6581
Taxonomy
Speciality
Code
Description
License number
State
261QM1101X
Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
Primary
—
—
Other
Enumeration date
10/24/2006
Last updated
08/22/2020
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