Healthcare Provider Details

I. General information

NPI: 1417044702
Provider Name (Legal Business Name): ACH BLANCHFIELD-FT CAMPBELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

650 JOEL DR ATTN UBO
FORT CAMPBELL KY
42223-5318
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8286
  • Fax: 270-798-8286
Mailing address:
  • Phone: 270-798-8286
  • Fax: 270-956-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code341800000X
TaxonomyMilitary/U.S. Coast Guard Transport,
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MS. SHARON L TUCKER
Title or Position: UBO MANAGER
Credential:
Phone: 270-798-8286