MEDICARE: PHILIP TRENT IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman		CA

General Provider Information

NPI Number	:	1043752066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP TRENT IDC

Provider Business Mailing Address
First Line	:	2615 KILMARNOCK CT
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-4083
Country	:	US
Telephone Number	:	704-619-8656
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS O'KANE
Second Line	:	DDG,BOX 1, UNIT 100189
City	:	FPO
State	:	AP
Zip	:	96674
Country	:	US
Telephone Number	:	808-471-0741
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2016
Last Update Date	:	11/08/2016

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Directions to “ PHILIP TRENT IDC” Practice Location

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