Healthcare Provider Details

I. General information

NPI: 1851368229
Provider Name (Legal Business Name): CARLOS M. COLEMAN IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 FARENHOLT AVE NSHS-SD IDC DEPT
SAN DIEGO CA
92134-7000
US

IV. Provider business mailing address

1418 TRAILWOOD AVE
CHULA VISTA CA
91913-2964
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-5109
  • Fax:
Mailing address:
  • Phone: 619-985-5915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: