MEDICARE: LON PHILLIP CHANEY 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710-1002X	OTHER		IDC

General Provider Information

NPI Number	:	1912342536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LON PHILLIP CHANEY IDC

Provider Business Mailing Address
First Line	:	2626 SHOUP DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4268
Country	:	US
Telephone Number	:	757-641-3994
Fax Number	:

Provider Business Practice Location Address
First Line	:	2626 SHOUP DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4268
Country	:	US
Telephone Number	:	757-641-3994
Fax Number	:

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

Provider Enumeration Date	:	05/09/2013
Last Update Date	:	05/09/2013

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Directions to “ LON PHILLIP CHANEY IDC” Practice Location

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