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General NPI Number Information
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NPI Number | 1891765046
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Entity Type | Organization
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Legal Business Name | 412TH MEDGRP-EDWARDS
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Dates
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Enumeration Date | 01/23/2006
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Last Update Date | 06/16/2025
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Provider Practice Location Address
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Address Line | 30 NIGHTINGALE RD BLDG 5525
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City | EDWARDS AFB
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State | CA
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Zip | 93524-0001
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Country | US
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Telephone | 661-275-2634
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Fax | 661-277-6645
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Provider Business Mailing Address
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Address Line | 30 NIGHTINGALE RD BLDG 5525
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City | EDWARDS AFB
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State | CA
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Zip | 93524-0001
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Country | US
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Telephone | 661-275-2634
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Fax | 661-277-6645
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Authorized Official
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Title or Position | AIR FORCE UBO ANALYST
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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 | 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 #2
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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 #3
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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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