Healthcare Provider Details

I. General information

NPI: 1609859891
Provider Name (Legal Business Name): 633D MEDGRP-JB LANGLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NEALY AVE
LANGLEY AFB VA
23665-2040
US

IV. Provider business mailing address

77 NEALY AVE
LANGLEY AFB VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-6807
  • Fax: 757-764-0821
Mailing address:
  • Phone: 757-764-6807
  • Fax: 757-764-0821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEN LEWANDOWSKI
Title or Position: DHA FINANCIAL MANAGER
Credential:
Phone: 703-817-4030