Provider Demographics
NPI:1821410242
Name:LYSTER ARMY HEALTH CLINIC
Entity Type:Organization
Organization Name:LYSTER ARMY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NREMT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-255-7636
Mailing Address - Street 1:BUILDING 301 ANDREWS AVENUE
Mailing Address - Street 2:LYSTER ARMY HEALTH CLINIC
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5333
Mailing Address - Country:US
Mailing Address - Phone:334-255-7636
Mailing Address - Fax:334-255-7368
Practice Address - Street 1:LYSTER ARMY HEALTH CLINIC
Practice Address - Street 2:BUILDING 301 ANDREWS AVENUE
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:334-255-7636
Practice Address - Fax:334-255-7368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2089197261QM1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient