MEDICARE: RYAN GREGORY GARDINER I.D.C.

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	:	1538427968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN GREGORY GARDINER I.D.C.

Provider Business Mailing Address
First Line	:	4663 MUIR AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-2243
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2348 TRIDENT WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92155-5508
Country	:	US
Telephone Number	:	910-280-2206
Fax Number	:

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

Provider Enumeration Date	:	04/23/2012
Last Update Date	:	04/23/2012

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