MEDICARE: 30TH MEDGRP-VANDENBERG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM1101X	Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
2	332000000X	Military/U.S. Coast Guard Pharmacy
3	261QM1100X	Military/U.S. Coast Guard Outpatient Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05-49759	OTHER	CA	NCPDP

General Provider Information

NPI Number	:	1477536126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	30TH MEDGRP-VANDENBERG

Provider Business Mailing Address
First Line	:	338 S DAKOTA AVE
Second Line	:
City	:	VANDENBERG AFB
State	:	CA
Zip	:	93437-6307
Country	:	US
Telephone Number	:	805-606-3012
Fax Number	:	805-606-4474

Provider Business Practice Location Address
First Line	:	338 S DAKOTA AVE
Second Line	:
City	:	VANDENBERG AFB
State	:	CA
Zip	:	93437-6307
Country	:	US
Telephone Number	:	805-606-3012
Fax Number	:	805-606-4474

Authorized Official
Title or Position	:	DEFENSE HEALTH AGENCY (DHA) FINANCI
Name	:	JEN LEWANDOWSKI
Credential	:
Telephone Number	:	703-817-4030

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	06/12/2025

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Directions to “30TH MEDGRP-VANDENBERG ” Practice Location

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