Provider Demographics
NPI:1346654175
Name:17 MEDICAL GROUP
Entity Type:Organization
Organization Name:17 MEDICAL GROUP
Other - Org Name:DOD GOODFELLOW EPHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF DHA PASS
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-536-6650
Mailing Address - Street 1:17 MEDICAL GROUP
Mailing Address - Street 2:271 FORT RICHARDSON AVE.
Mailing Address - City:GOODFELLOW AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76908
Mailing Address - Country:US
Mailing Address - Phone:325-654-3101
Mailing Address - Fax:325-654-5898
Practice Address - Street 1:271 FORT RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:GOODFELLOW AFB
Practice Address - State:TX
Practice Address - Zip Code:76908-4901
Practice Address - Country:US
Practice Address - Phone:325-654-3101
Practice Address - Fax:325-654-5898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146403OtherPK