Healthcare Provider Details

I. General information

NPI: 1912982810
Provider Name (Legal Business Name): 377TH MEDGRP-KIRTLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050A SECOND ST SE
KIRTLAND AFB NM
87117-5524
US

IV. Provider business mailing address

2050A SECOND ST SE
KIRTLAND AFB NM
87117-5524
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-3605
  • Fax: 505-846-3594
Mailing address:
  • Phone: 505-846-3605
  • Fax: 505-846-3594

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: DHA UBO
Credential:
Phone: 703-817-4030