Provider Demographics
NPI:1598315392
Name:VANDENBERG AIR FORCE 30TH MEDICAL GROUP
Entity Type:Organization
Organization Name:VANDENBERG AIR FORCE 30TH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH PROMOTION DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTAGALOA-WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED DIETITIAN
Authorized Official - Phone:805-606-3469
Mailing Address - Street 1:338 S DAKOTA AVE BLDG 13850
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93437-6307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE BLDG 13850
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93437-6307
Practice Address - Country:US
Practice Address - Phone:805-606-3469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty