Healthcare Provider Details

I. General information

NPI: 1306049895
Provider Name (Legal Business Name): RAYMOND W. BLISS ARMY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45005 ARIZONA STREET
FORT HUACHUCA AZ
85613
US

IV. Provider business mailing address

2240 E WINROW AVE ATTN MCXJ-RMD-MSAO
FORT HUACHUCA AZ
85613-7079
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-1479
  • Fax:
Mailing address:
  • Phone: 520-533-9685
  • 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: FAYE LIVINGSTON
Title or Position: UBO MANAGER
Credential:
Phone: 520-533-9685