MEDICARE: TIFFANY RENEE O'NEAL 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	:	1598283616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY RENEE O'NEAL IDC

Provider Business Mailing Address
First Line	:	1775 ORO VISTA RD APT 194
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-4516
Country	:	US
Telephone Number	:	770-371-3622
Fax Number	:

Provider Business Practice Location Address
First Line	:	1775 ORO VISTA RD APT 194
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-4516
Country	:	US
Telephone Number	:	770-371-3622
Fax Number	:

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

Provider Enumeration Date	:	09/08/2017
Last Update Date	:	07/21/2022

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