Provider Demographics
NPI:1144323650
Name:WILFORD HALL MEDICAL CENTER
Entity type:Organization
Organization Name:WILFORD HALL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARLON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-292-6707
Mailing Address - Street 1:2200 BERQUIST DRIVE, SUITE 1
Mailing Address - Street 2:ATTN: CREDENTIALS (CMC)
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18200 BLANCO SPGS APT 112
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4562
Practice Address - Country:US
Practice Address - Phone:559-731-6195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital