Healthcare Provider Details

I. General information

NPI: 1780657239
Provider Name (Legal Business Name): 10TH MEDGRP-ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR 10 MDSS SGSB
USAF ACADEMY CO
80840-2502
US

IV. Provider business mailing address

4102 PINION DR 10 MDSS SGSB
USAF ACADEMY CO
80840-2502
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5648
  • Fax: 719-333-5202
Mailing address:
  • Phone: 719-333-5648
  • Fax: 719-333-5202

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

VIII. Authorized Official

Name: JEN LEWANDOWSKI
Title or Position: AIR FORCE UNIFORM BUSINESS OFFICE
Credential:
Phone: 703-817-4030