Healthcare Provider Details

I. General information

NPI: 1598315392
Provider Name (Legal Business Name): VANDENBERG AIR FORCE 30TH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 S DAKOTA AVE BLDG 13850
LOMPOC CA
93437-6307
US

IV. Provider business mailing address

338 S DAKOTA AVE BLDG 13850
LOMPOC CA
93437-6307
US

V. Phone/Fax

Practice location:
  • Phone: 805-606-3469
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MARY MUTAGALOA-WALKER
Title or Position: HEALTH PROMOTION DIETITIAN
Credential: REGISTERED DIETITIAN
Phone: 805-606-3469