Healthcare Provider Details

I. General information

NPI: 1144423617
Provider Name (Legal Business Name): AHC LYSTER-RUCKER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/09/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 INNKEEPER STREET
FORT RUCKER AL
36362
US

IV. Provider business mailing address

301 ANDREWS ROAD ATTN MCXY-RM-TPCP
FORT RUCKER AL
36362-5000
US

V. Phone/Fax

Practice location:
  • Phone: 334-255-7000
  • Fax:
Mailing address:
  • Phone: 334-255-7244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARBARA BROWN
Title or Position: UBO MANAGER
Credential:
Phone: 334-255-7244