Provider Demographics
NPI:1972871838
Name:UNITED STATES PUBLIC HEALTH SERVICE
Entity type:Organization
Organization Name:UNITED STATES PUBLIC HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICE ADMINITRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JONHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-779-6052
Mailing Address - Street 1:1623 E J ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98421-1602
Mailing Address - Country:US
Mailing Address - Phone:253-552-4947
Mailing Address - Fax:253-779-6005
Practice Address - Street 1:1623 E J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98421-1602
Practice Address - Country:US
Practice Address - Phone:253-552-4947
Practice Address - Fax:253-779-6005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005661251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare