Organization · NPI-2

17th Medgrp-Goodfellow

Clinic/Center, MilitaryU.S. Coast Guard Outpatient · Goodfellow Afb, TX

NPI number1104805142

StatusActive

Last updated in NPPESJun 17, 2025

Details

NPI: 1104805142
Entity type: Organization (NPI-2)
Legal business name: 17th Medgrp-Goodfellow
Organization subpart: Yes
Enumeration date: Jan 10, 2006
Certification date: Jun 17, 2025
Last updated: Jun 17, 2025

Taxonomy and licenses

Taxonomy code	Description	License	State	Primary
261QM1100X	Clinic/Center, MilitaryU.S. Coast Guard Outpatient	–	TX	Yes
261QM1101X	Clinic/Center, Military and U.S. Coast Guard Ambulatory Procedure	–	–
332000000X	MilitaryU.S. Coast Guard Pharmacy	–	–

Practice location

271 Fort Richardson Ave
Goodfellow Afb, TX 76908-4901

Phone 325-654-5974 · Fax 325-654-3121

Mailing address

271 Fort Richardson Ave
Goodfellow Afb, TX 76908-4901

Phone 325-654-5974 · Fax 325-654-3121

Authorized official

Jen Lewandowski
Dha Ubo
7038174030

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