Healthcare Provider Details

I. General information

NPI: 1811960149
Provider Name (Legal Business Name): RAYMOND W. BLISS HEALTH CEMTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2240 E. WINROW AVE. MEDDAC
FT. HUACHUCA AZ
85613
US

IV. Provider business mailing address

600 CHANTILLY DR
SIERRA VISTA AZ
85635-4732
US

V. Phone/Fax

Practice location:
  • Phone: 520-538-1546
  • Fax:
Mailing address:
  • Phone: 520-459-6698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License NumberLP028575
License Number StateAZ

VIII. Authorized Official

Name: MRS. GUADALUPE VAN HUSS
Title or Position: NURSE
Credential: LPN
Phone: 520-538-1546