Provider Demographics
NPI:1124486840
Name:USA MEDDAC, RWBAHC
Entity type:Organization
Organization Name:USA MEDDAC, RWBAHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-533-9034
Mailing Address - Street 1:2240 WINROW AVE
Mailing Address - Street 2:
Mailing Address - City:FT.HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613-7079
Mailing Address - Country:US
Mailing Address - Phone:520-533-9034
Mailing Address - Fax:520-533-5148
Practice Address - Street 1:2240 E WINROW AVE
Practice Address - Street 2:USA MEDDAC, RWBAHC
Practice Address - City:FT. HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-9034
Practice Address - Fax:520-533-5148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP 00041579261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care