MEDICARE: MR. RICARDO VANN JR. 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	:	1326397597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICARDO VANN JR. IDC

Provider Business Mailing Address
First Line	:	10179 HOOPER ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-3510
Country	:	US
Telephone Number	:	619-840-7572
Fax Number	:

Provider Business Practice Location Address
First Line	:	HM2 VANN, RICARDO
Second Line	:	MED
City	:	FPO
State	:	AP
Zip	:	96629
Country	:	US
Telephone Number	:	619-545-3616
Fax Number	:

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

Provider Enumeration Date	:	09/04/2012
Last Update Date	:	10/29/2012

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