MEDICARE: TROY DENESTY HAYNES 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	:	1538333091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TROY DENESTY HAYNES IDC

Provider Business Mailing Address
First Line	:	2108 SCOTLAND ST
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456
Country	:	US
Telephone Number	:	910-382-1658
Fax Number	:

Provider Business Practice Location Address
First Line	:	2108 SCOTLAND ST
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456
Country	:	US
Telephone Number	:	910-382-1658
Fax Number	:

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

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	04/16/2008

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