Basic Information
| Provider Information | |||||||||
| NPI: | 1982812640 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLANCHFIELD ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA POINTE HLTH CLINIC-CAMPBELL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | ATTN UBO | ||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988286 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5979 DESERT STORM AVE | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703630312 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TUCKER | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2707988286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BLANCHFIELD ARMY COMMUNITY HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
ID Information
| ID | Type | State | Issuer | Description | AN2598588 | 01 | MEDCO | OTHER |