Healthcare Provider Details

I. General information

NPI: 1932760568
Provider Name (Legal Business Name): SUSAN LEROY JOSLIN IDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 TWAIN AVE APT 284
SAN DIEGO CA
92120-3478
US

IV. Provider business mailing address

4440 TWAIN AVE APT 284
SAN DIEGO CA
92120-3478
US

V. Phone/Fax

Practice location:
  • Phone: 915-603-0520
  • Fax:
Mailing address:
  • Phone: 915-603-0520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: