Healthcare Provider Details

I. General information

NPI: 1558332080
Provider Name (Legal Business Name): RAYMOND W BLISS ARMY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 WINROW RD
FT HUACHUCA AZ
85613-5080
US

IV. Provider business mailing address

7935 E CONNOR RD
SIERRA VISTA AZ
85650-9081
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-2627
  • Fax:
Mailing address:
  • Phone: 520-803-6793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License NumberLP028519
License Number StateAZ

VIII. Authorized Official

Name: MRS. LINDA SUE HALDORSON
Title or Position: LICIENSED PRACTICAL NURSE
Credential: LPN
Phone: 520-533-2627