Healthcare Provider Details

I. General information

NPI: 1568446524
Provider Name (Legal Business Name): 673D MEDGRP-JBER ELMNDRF-RICH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1782 HACKETT DR
LA PINE OR
97739-9118
US

IV. Provider business mailing address

25016 HENDON ST
LAGUNA HILLS CA
92653-4629
US

V. Phone/Fax

Practice location:
  • Phone: 442-245-4585
  • Fax:
Mailing address:
  • Phone: 442-245-4585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
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 TaxonomyN
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEN LEWANDOWSKI
Title or Position: AIR FORCE UBO ANALYST
Credential:
Phone: 703-817-4030