Healthcare Provider Details

I. General information

NPI: 1952374910
Provider Name (Legal Business Name): 49TH MEDGRP-HOLLOMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 1ST ST SGSR
HOLLOMAN AFB NM
88330-8273
US

IV. Provider business mailing address

280 1ST ST SGSR
HOLLOMAN AFB NM
88330-8273
US

V. Phone/Fax

Practice location:
  • Phone: 505-572-5744
  • Fax: 505-572-0549
Mailing address:
  • Phone: 505-572-5744
  • Fax: 505-572-0549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 3
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: DHA UBO
Credential:
Phone: 703-817-4030