MEDICARE: CHASE SPEED 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	100134047	SC

General Provider Information

NPI Number	:	1609301134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHASE SPEED IDC

Provider Business Mailing Address
First Line	:	1440 HOTEL CIR N
Second Line	:	APT 467
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-2906
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1440 HOTEL CIR N
Second Line	:	APT 467
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-2906
Country	:	US
Telephone Number	:	803-378-1205
Fax Number	:

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

Provider Enumeration Date	:	04/21/2017
Last Update Date	:	04/21/2017

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Directions to “ CHASE SPEED IDC” Practice Location

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