MEDICARE: MRS. JADE MARIE MEDDERS EMT-B

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	146N00000X	Basic Emergency Medical Technician	EMT509305	FL
2	183700000X	Pharmacy Technician	280101040340690	DC

General Provider Information

NPI Number	:	1750626172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JADE MARIE MEDDERS EMT-B

Provider Business Mailing Address
First Line	:	PO BOX 291938
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-1938
Country	:	US
Telephone Number	:	386-562-4070
Fax Number	:	386-760-0532

Provider Business Practice Location Address
First Line	:	725 DUNLAWTON AVE
Second Line	:	#291938
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-7001
Country	:	US
Telephone Number	:	386-562-4070
Fax Number	:	386-492-6941

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

Provider Enumeration Date	:	12/11/2012
Last Update Date	:	10/04/2016

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