Organization
366TH MEDGRP-MOUNTAIN HOME
Active
Parent organization
366TH MEDGRP-MOUNTAIN HOME
Organization subpart
Yes
Provider details
NPI number
Legal business name
366TH MEDGRP-MOUNTAIN HOME
Authorized official
JEN LEWANDOWSKI (DHA UBO)
(703) 817-4030
Entity
Organization
Contact information
Practice address
90 HOPE DRIVE BLDG 6000, 366 MEDICAL GROUP, MOUNTAIN HOME AFB, ID 83648-1062
(208) 828-7470
(208) 828-2753
Mailing address
90 HOPE DRIVE BLDG 6000, 366 MEDICAL GROUP SGSR, MOUNTAIN HOME AFB, ID 83648-1062
(208) 828-7470
(208) 828-2753
Taxonomy
Speciality
Code
Description
License number
State
261QM1100X
Military/U.S. Coast Guard Outpatient Clinic/Center
—
—
261QM1101X
Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
Primary
—
—
332000000X
Military/U.S. Coast Guard Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1306845
NCPDP
ID
05
—
8072078
—
ID
Enumeration date
02/17/2006
Last updated
06/17/2025
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