Healthcare Provider Details

I. General information

NPI: 1538145412
Provider Name (Legal Business Name): 61ST MED SQ-LOS ANGELES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 VELA WAY SUITE 1866
EL SEGUNDO CA
90245-4659
US

IV. Provider business mailing address

2420 VELA WAY STE 1467
EL SEGUNDO CA
90245-4659
US

V. Phone/Fax

Practice location:
  • Phone: 310-363-6640
  • Fax: 310-363-0243
Mailing address:
  • Phone: 310-653-6437
  • Fax: 310-653-0243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEN LEWANDOWSKI
Title or Position: DHA UBO
Credential:
Phone: 703-817-4030