Healthcare Provider Details

I. General information

NPI: 1922181627
Provider Name (Legal Business Name): AHC R W BLISS-HUACHUCA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E WINROW AVE
FT HUACHUCA AZ
85613-7079
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 520-533-0447
  • Fax:
Mailing address:
  • Phone: 520-533-9685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESTINE VOLGENDE
Title or Position: UBO MANAGER
Credential:
Phone: 520-533-9685