MEDICARE: TADD OLIN KNOX RAGSDALE IDMT

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	1710I1003X	Independent Duty Medical Technicians

General Provider Information

NPI Number	:	1558700104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TADD OLIN KNOX RAGSDALE IDMT

Provider Business Mailing Address
First Line	:	3062 TROUTMAN DR
Second Line	:
City	:	BEALE AFB
State	:	CA
Zip	:	95903-2329
Country	:	US
Telephone Number	:	916-757-4603
Fax Number	:

Provider Business Practice Location Address
First Line	:	3062 TROUTMAN DR
Second Line	:
City	:	BEALE AFB
State	:	CA
Zip	:	95903-2329
Country	:	US
Telephone Number	:	916-757-4603
Fax Number	:

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

Provider Enumeration Date	:	06/17/2013
Last Update Date	:	06/17/2013

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