MEDICARE: MR. MICHAEL TAD GARRITSON 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	:	1598736449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL TAD GARRITSON IDC

Provider Business Mailing Address
First Line	:	5151 ROBINWOOD RD
Second Line	:	APT. 8
City	:	BONITA
State	:	CA
Zip	:	91902
Country	:	US
Telephone Number	:	619-992-6997
Fax Number	:

Provider Business Practice Location Address
First Line	:	2446 TRIDENT WAY
Second Line	:	MEDICAL CLINIC
City	:	SAN DIEGO
State	:	CA
Zip	:	92155-5494
Country	:	US
Telephone Number	:	619-437-0777
Fax Number	:

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	07/08/2007

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