Healthcare Provider Details

I. General information

NPI: 1861477176
Provider Name (Legal Business Name): USAF ACTIVE DUTY
Entity Type: Organization
Gender:
Sole Proprietor:

Provider Other Name: RAF LAKENHEATH OR 48TH MED GRP

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48TH MEDICAL GRP RAF LAKENHEATH UNIT 5210
APO AE
09464-5210
US

IV. Provider business mailing address

BOX 230 UNIT 5210
APO AE
09464-5210
US

V. Phone/Fax

Practice location:
  • Phone: 01638528703
  • Fax:
Mailing address:
  • Phone: 01638528703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State

VIII. Authorized Official

Name: SERENA LYNN HANSKEN
Title or Position: AIR FORCE UNIFORM BUSINESS OFFICE
Credential:
Phone: 703-588-6419