Provider Demographics
NPI:1366610115
Name:LYSTER ARMY HEALTH CLINIC
Entity type:Organization
Organization Name:LYSTER ARMY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNA
Authorized Official - Prefix:MS
Authorized Official - First Name:EVON
Authorized Official - Middle Name:HILL
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-255-7118
Mailing Address - Street 1:DEPT OF THE ARMY DEPT OF PRIMARY CARE&COMMUNITY MED.
Mailing Address - Street 2:BLDG 301
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362
Mailing Address - Country:US
Mailing Address - Phone:334-255-7118
Mailing Address - Fax:334-255-7090
Practice Address - Street 1:DEPT OF PRIMARY CARE&COMMUNITY MED
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-7118
Practice Address - Fax:334-255-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care