MEDICARE: MRS. KELLY D HOFFER 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	1710I1003X	Independent Duty Medical Technicians

General Provider Information

NPI Number	:	1174731962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY D HOFFER IDC

Provider Business Mailing Address
First Line	:	2028 MASON NECK LN
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8761
Country	:	US
Telephone Number	:	757-445-9034
Fax Number	:

Provider Business Practice Location Address
First Line	:	1084 POCAHONTAS ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23511-2133
Country	:	US
Telephone Number	:	757-445-9034
Fax Number	:

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

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	07/08/2007

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