Provider Demographics
NPI:1053406348
Name:COMDT(CG-1122) U.S. CAOST GUARD
Entity type:Organization
Organization Name:COMDT(CG-1122) U.S. CAOST GUARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICES TECHNICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:YUSUF
Authorized Official - Middle Name:D'COBLA
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-856-2230
Mailing Address - Street 1:2100 2ND ST SW
Mailing Address - Street 2:SUITE 5314
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20593-0002
Mailing Address - Country:US
Mailing Address - Phone:757-856-2230
Mailing Address - Fax:757-856-2276
Practice Address - Street 1:2100 2ND ST SW
Practice Address - Street 2:SUITE 5314
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20593-0002
Practice Address - Country:US
Practice Address - Phone:757-856-2230
Practice Address - Fax:757-856-2276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC24720000X247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========OtherSSN