Provider Demographics
NPI:1881779353
Name:USA MEDDAC, RWBACH
Entity type:Organization
Organization Name:USA MEDDAC, RWBACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR, ASAP
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUBALA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LISAC
Authorized Official - Phone:520-533-2071
Mailing Address - Street 1:2240 WINROW AVE
Mailing Address - Street 2:
Mailing Address - City:FORT HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613
Mailing Address - Country:US
Mailing Address - Phone:520-533-2071
Mailing Address - Fax:
Practice Address - Street 1:2240 WINROW AVE
Practice Address - Street 2:
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-2071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC 1029261QR0405X
AZLCSW 0611261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder