Provider Demographics
NPI:1023246659
Name:UNITED STATES AIR FORCE
Entity type:Organization
Organization Name:UNITED STATES AIR FORCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT DUTY MEDICAL TECHNICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GODBOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-963-6936
Mailing Address - Street 1:204 W HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29404-4704
Mailing Address - Country:US
Mailing Address - Phone:843-963-6936
Mailing Address - Fax:843-963-6903
Practice Address - Street 1:204 W HILL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON AFB
Practice Address - State:SC
Practice Address - Zip Code:29404-4704
Practice Address - Country:US
Practice Address - Phone:843-963-6936
Practice Address - Fax:843-963-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center