MEDICARE: TERESA ELEANOR MCCORMICK

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	164X00000X	Licensed Vocational Nurse	VN687288	CA

General Provider Information

NPI Number	:	1336647031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA ELEANOR MCCORMICK

Provider Business Mailing Address
First Line	:	4203 TORRAZZO WAY
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-5444
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4203 TORRAZZO WAY
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-5444
Country	:	US
Telephone Number	:	720-355-9169
Fax Number	:

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

Provider Enumeration Date	:	01/28/2018
Last Update Date	:	01/28/2018

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