MEDICARE: RICHARD EDUARDO MASCIONI 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	:	1831379130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD EDUARDO MASCIONI IDC

Provider Business Mailing Address
First Line	:	800 SEAL BEACH BLVD
Second Line	:	#22
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-5607
Country	:	US
Telephone Number	:	562-626-7285
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 SEAL BEACH BLVD
Second Line	:	#22
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-5607
Country	:	US
Telephone Number	:	562-626-7285
Fax Number	:

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

Provider Enumeration Date	:	11/05/2007
Last Update Date	:	11/05/2007

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