Healthcare Provider Details

I. General information

NPI: 1366610115
Provider Name (Legal Business Name): LYSTER ARMY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPT OF PRIMARY CARE&COMMUNITY MED
FORT RUCKER AL
36362
US

IV. Provider business mailing address

DEPT OF THE ARMY DEPT OF PRIMARY CARE&COMMUNITY MED. BLDG 301
FORT RUCKER AL
36362
US

V. Phone/Fax

Practice location:
  • Phone: 334-255-7118
  • Fax: 334-255-7090
Mailing address:
  • Phone: 334-255-7118
  • Fax: 334-255-7090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. EVON HILL SHAW
Title or Position: CNA
Credential:
Phone: 334-255-7118