MEDICARE: HARRY F DEROCHEMONT

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	172A00000X	Driver

General Provider Information

NPI Number	:	1790452761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HARRY F DEROCHEMONT

Provider Business Mailing Address
First Line	:	1640 CAMINO DEL RIO N STE 881256
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1506
Country	:	US
Telephone Number	:	619-317-3207
Fax Number	:

Provider Business Practice Location Address
First Line	:	1640 CAMINO DEL RIO N STE 202
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1523
Country	:	US
Telephone Number	:	619-317-3207
Fax Number	:

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

Provider Enumeration Date	:	08/26/2021
Last Update Date	:	08/26/2021

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Directions to “ HARRY F DEROCHEMONT ” Practice Location

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