Healthcare Provider Details

I. General information

NPI: 1083965461
Provider Name (Legal Business Name): JARED LYNN ALEXANDER IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS LPD 9 DENVER
FPO AP
96663-1712
US

IV. Provider business mailing address

1936 THIBODO RD APT 207
VISTA CA
92081-7944
US

V. Phone/Fax

Practice location:
  • Phone: 01181956501210
  • Fax:
Mailing address:
  • Phone: 406-529-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: