Provider Demographics
NPI:1568442630
Name:1ST SPCL OPS MEDGRP-HURLBURT
Entity type:Organization
Organization Name:1ST SPCL OPS MEDGRP-HURLBURT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DHA FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWANDOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-817-4030
Mailing Address - Street 1:113 LIELMANIS AVE
Mailing Address - Street 2:
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-5613
Mailing Address - Country:US
Mailing Address - Phone:850-881-2331
Mailing Address - Fax:
Practice Address - Street 1:113 LIELMANIS AVE
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5613
Practice Address - Country:US
Practice Address - Phone:850-881-2331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1ST SPCL OPS MEDGRP-HURLBURT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-17
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1088788OtherNCPDP
FLOTH000Medicare UPIN