Healthcare Provider Details

I. General information

NPI: 1881779353
Provider Name (Legal Business Name): USA MEDDAC, RWBACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 WINROW AVE
FORT HUACHUCA AZ
85613
US

IV. Provider business mailing address

2240 WINROW AVE
FORT HUACHUCA AZ
85613
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-2071
  • Fax:
Mailing address:
  • Phone: 520-533-2071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberLISAC 1029
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberLCSW 0611
License Number StateAZ

VIII. Authorized Official

Name: MR. JOSEPH A BUBALA
Title or Position: CLINICAL DIRECTOR, ASAP
Credential: LCSW, LISAC
Phone: 520-533-2071