MEDICARE: MR. DION ERICSON BLAKE 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	:	1922076827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DION ERICSON BLAKE IDC

Provider Business Mailing Address
First Line	:	1035 NW 155TH TER
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33028-1514
Country	:	US
Telephone Number	:	954-804-8731
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS JOHN L. HALL
Second Line	:	FPO AA 34091
City	:	JACKSONVILLE
State	:	FL
Zip	:	32228
Country	:	US
Telephone Number	:	904-270-6541
Fax Number	:

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	03/07/2008

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