Healthcare Provider Details

I. General information

NPI: 1417776501
Provider Name (Legal Business Name): HUACHUCA HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 E FRY BLVD STE F
SIERRA VISTA AZ
85635-2683
US

IV. Provider business mailing address

1048 E FRY BLVD STE F
SIERRA VISTA AZ
85635-2683
US

V. Phone/Fax

Practice location:
  • Phone: 520-458-9450
  • Fax:
Mailing address:
  • Phone: 520-458-9450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: AMBER L TUELLER
Title or Position: TREASURER
Credential:
Phone: 208-207-2726