Healthcare Provider Details

I. General information

NPI: 1548369259
Provider Name (Legal Business Name): 21ST MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST
PETERSON AFB CO
80914-1541
US

IV. Provider business mailing address

559 VINCENT ST
PETERSON AFB CO
80914-1541
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-2273
  • Fax: 719-556-1106
Mailing address:
  • Phone: 719-333-2273
  • Fax: 719-556-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HECTOR MORALES
Title or Position: CHIEF DHA PASS
Credential:
Phone: 210-536-6650