Provider Demographics
NPI:1386886489
Name:UNITED STATES NAVY
Entity type:Organization
Organization Name:UNITED STATES NAVY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT DUTY CORPSMAN
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:IDC
Authorized Official - Phone:843-574-8242
Mailing Address - Street 1:48 HICKORY HALL LN
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-6318
Mailing Address - Country:US
Mailing Address - Phone:360-689-9072
Mailing Address - Fax:
Practice Address - Street 1:3600 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WA
Practice Address - Zip Code:29405
Practice Address - Country:US
Practice Address - Phone:843-574-8242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QM1103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1103XAmbulatory Health Care FacilitiesClinic/CenterMilitary Ambulatory Procedure Visits Operational (Transportable)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherPERSONNEL IDENTIFICATION NUMBER