MEDICARE: RYAN TYLER BADILLO SFIDC

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1952984254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN TYLER BADILLO SFIDC

Provider Business Mailing Address
First Line	:	PSC 1012 BOX 392
Second Line	:
City	:	FPO
State	:	AA
Zip	:	34058-0004
Country	:	US
Telephone Number	:	252-515-8641
Fax Number	:

Provider Business Practice Location Address
First Line	:	WHITE BLIGHT
Second Line	:
City	:	ANDROS TOWN
State	:	ANDROS ISLAND
Zip	:	34058
Country	:	BS
Telephone Number	:	252-515-8641
Fax Number	:

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

Provider Enumeration Date	:	05/04/2021
Last Update Date	:	12/28/2021

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