MEDICARE: MR. RANDY SCOTT BREIDEL SUB 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

General Provider Information

NPI Number	:	1265401673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDY SCOTT BREIDEL SUB IDC

Provider Business Mailing Address
First Line	:	761 DWYER RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-6924
Country	:	US
Telephone Number	:	757-689-8742
Fax Number	:

Provider Business Practice Location Address
First Line	:	DAM NECK ANNEX
Second Line	:	1885 TERRIER AVE STE 100
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23461-2298
Country	:	US
Telephone Number	:	757-314-7221
Fax Number	:

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

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/21/2022

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