MEDICARE: MR. FERDINAND NMI MAKABATA 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	:	1790041192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FERDINAND NMI MAKABATA IDMT

Provider Business Mailing Address
First Line	:	1406 HARDY CASH DR
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-2434
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1406 HARDY CASH DR
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-2434
Country	:	US
Telephone Number	:	757-304-2893
Fax Number	:

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

Provider Enumeration Date	:	04/10/2012
Last Update Date	:	04/10/2012

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