Provider Demographics
NPI:1255519740
Name:LYSTER ARMY HEALTH CLINIC
Entity type:Organization
Organization Name:LYSTER ARMY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BOOZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-255-7033
Mailing Address - Street 1:ANDREWS AVENUE
Mailing Address - Street 2:BLDG 301
Mailing Address - City:FT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362
Mailing Address - Country:US
Mailing Address - Phone:334-255-7033
Mailing Address - Fax:
Practice Address - Street 1:ANDREWS AVE
Practice Address - Street 2:BUILDING 301
Practice Address - City:FT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-7033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-044039261QM1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1102XAmbulatory Health Care FacilitiesClinic/CenterMilitary Outpatient Operational (Transportable) Component