Healthcare Provider Details

I. General information

NPI: 1124486840
Provider Name (Legal Business Name): USA MEDDAC, RWBAHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E WINROW AVE USA MEDDAC, RWBAHC
FT. HUACHUCA AZ
85613
US

IV. Provider business mailing address

2240 WINROW AVE
FT.HUACHUCA AZ
85613-7079
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-9034
  • Fax: 520-533-5148
Mailing address:
  • Phone: 520-533-9034
  • Fax: 520-533-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberLP 00041579
License Number StateWA

VIII. Authorized Official

Name: MS. CAROL JEAN PHILLIPS
Title or Position: LPN
Credential:
Phone: 520-533-9034