Healthcare Provider Details

I. General information

NPI: 1588647770
Provider Name (Legal Business Name): 96TH MEDGRP-EGLIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD SUITE 114
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

307 BOATNER RD SUITE 114
EGLIN AFB FL
32542-1302
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-9015
  • Fax: 850-883-8659
Mailing address:
  • Phone: 850-883-9015
  • Fax: 850-883-8659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

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