MEDICARE: SIR DUPLECHAN

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1891567939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIR DUPLECHAN

Provider Business Mailing Address
First Line	:	21198 BEAUJOLAIS WAY
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-5843
Country	:	US
Telephone Number	:	661-728-6292
Fax Number	:

Provider Business Practice Location Address
First Line	:	21198 BEAUJOLAIS WAY
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-5843
Country	:	US
Telephone Number	:	661-728-6292
Fax Number	:

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

Provider Enumeration Date	:	10/23/2023
Last Update Date	:	10/23/2023

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Directions to “ SIR DUPLECHAN ” Practice Location

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