MEDICARE: MR. KEVIN GOOCH 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		CA

General Provider Information

NPI Number	:	1639571359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN GOOCH IDC

Provider Business Mailing Address
First Line	:	4221 34TH ST
Second Line	:	APT #25
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-1400
Country	:	US
Telephone Number	:	910-388-4929
Fax Number	:

Provider Business Practice Location Address
First Line	:	4221 34TH ST
Second Line	:	APT #25
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-1400
Country	:	US
Telephone Number	:	760-365-7375
Fax Number	:

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

Provider Enumeration Date	:	09/24/2014
Last Update Date	:	02/08/2017

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