Provider Demographics
NPI:1902104284
Name:GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL
Other - Org Name:MEDDAC
Other - Org Type:Other Name
Authorized Official - Title/Position:NURSE SUPERVISER
Authorized Official - Prefix:MS
Authorized Official - First Name:DELORIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:MINKUS
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:573-596-1770
Mailing Address - Street 1:126 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-8952
Mailing Address - Country:US
Mailing Address - Phone:573-596-1770
Mailing Address - Fax:
Practice Address - Street 1:126 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-8952
Practice Address - Country:US
Practice Address - Phone:573-596-1770
Practice Address - Fax:573-596-1797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1546432865M2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital