MEDICARE: MR. ALLEN JAMES LAHEIST 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	:	1871560284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALLEN JAMES LAHEIST IDC

Provider Business Mailing Address
First Line	:	39837 WESTERN JAY WAY
Second Line	:
City	:	MURRIETA
State	:	CA
Zip	:	92562-4668
Country	:	US
Telephone Number	:	619-553-0838
Fax Number	:

Provider Business Practice Location Address
First Line	:	140 SYLVESTER RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-3521
Country	:	US
Telephone Number	:	619-553-0838
Fax Number	:

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

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	07/08/2007

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