MEDICARE: ZACHARY HALEY

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1164097366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHARY HALEY

Provider Business Mailing Address
First Line	:	3913 INGRAHAM ST APT U209
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-5921
Country	:	US
Telephone Number	:	508-409-9408
Fax Number	:

Provider Business Practice Location Address
First Line	:	3913 INGRAHAM ST APT U209
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-5921
Country	:	US
Telephone Number	:	508-409-9408
Fax Number	:

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

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	04/04/2022

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Directions to “ ZACHARY HALEY ” Practice Location

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