Organization
419 MEDICAL SQUADRON
Active
Organization
419 MEDICAL SQUADRON
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROBERT ATISME LISW, CSW (MENTAL HEALTH THERAPIST)
(801) 777-2622
Entity
Organization
Contact information
Practice address
7311 11TH ST, HILL AFB, UT 84056-5012
(801) 777-2622
Mailing address
3626 W 2000 N, WEST POINT, UT 84015-7300
(801) 776-8767
Taxonomy
Speciality
Code
Description
License number
State
276400000X
Substance Use Disorder Rehabilitation Hospital Unit
Primary
06477
IA
Other
Enumeration date
07/17/2006
Last updated
06/13/2008
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