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General NPI Number Information
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NPI Number | 1174507420
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Entity Type | Organization
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Legal Business Name | 460TH MEDGRP-BUCKLEY
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Dates
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Enumeration Date | 11/30/2005
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Last Update Date | 06/17/2025
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Provider Practice Location Address
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Address Line | 275 S ASPEN ST STOP 89
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City | AURORA
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State | CO
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Zip | 80011-9562
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Country | US
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Telephone | 720-277-9493
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Fax |
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Provider Business Mailing Address
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Address Line | 275 S ASPEN ST STOP 89
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City | AURORA
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State | CO
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Zip | 80011-9562
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Country | US
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Telephone | 720-277-9493
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Fax |
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Authorized Official
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Title or Position | DHA UBO
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Name | JEN LEWANDOWSKI
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Credential |
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Telephone | 703-817-4030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1101X
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Taxonomy Name | Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332000000X
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Taxonomy Name | Military/U.S. Coast Guard Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM1100X
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Taxonomy Name | Military/U.S. Coast Guard Outpatient Clinic/Center
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License Number |
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License Number State |
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