MEDICARE: TERRY DWAYNE SHOULDERS 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	:	1891949616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRY DWAYNE SHOULDERS IDC

Provider Business Mailing Address
First Line	:	3375 GREGORY ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-4751
Country	:	US
Telephone Number	:	760-668-5569
Fax Number	:

Provider Business Practice Location Address
First Line	:	3402 TARAWA RD.
Second Line	:	SPECIAL BOAT TEAM TWELVE MEDICAL DEPARTMENT
City	:	SAN DIEGO
State	:	CA
Zip	:	92155-5003
Country	:	US
Telephone Number	:	619-437-5540
Fax Number	:

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

Provider Enumeration Date	:	11/06/2008
Last Update Date	:	11/06/2008

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