MEDICARE: JACQUELINE ANN LADUE 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	:	1548603061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE ANN LADUE IDC

Provider Business Mailing Address
First Line	:	6482 AMBROSIA DR
Second Line	:	APT 5110
City	:	SAN DIEGO
State	:	CA
Zip	:	92124
Country	:	US
Telephone Number	:	757-402-0726
Fax Number	:

Provider Business Practice Location Address
First Line	:	6482 AMBROSIA DR
Second Line	:	APT 5110
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-3160
Country	:	US
Telephone Number	:	757-402-0726
Fax Number	:

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

Provider Enumeration Date	:	04/15/2013
Last Update Date	:	04/15/2013

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