MEDICARE: LEO STEVEN RODRIGUEZ 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	:	1811189293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEO STEVEN RODRIGUEZ IDC

Provider Business Mailing Address
First Line	:	28525 PLANTAIN ST
Second Line	:
City	:	MENIFEE
State	:	CA
Zip	:	92584-7495
Country	:	US
Telephone Number	:	951-269-3161
Fax Number	:

Provider Business Practice Location Address
First Line	:	BMA SAN NICOLAS IS
Second Line	:	NAVAL OUTLYING LANDING FIELD
City	:	POINT MUGU NAWC
State	:	CA
Zip	:	93042-0001
Country	:	US
Telephone Number	:	805-989-8030
Fax Number	:

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

Provider Enumeration Date	:	08/09/2007
Last Update Date	:	02/23/2012

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