1104206705 NPI number — JEREMY DANIEL HOWARD ATC, CES, PES

Table of content: JEREMY DANIEL HOWARD ATC, CES, PES (NPI 1104206705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104206705 NPI number — JEREMY DANIEL HOWARD ATC, CES, PES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOWARD
Provider First Name:
JEREMY
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC, CES, PES
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104206705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17460 ORIOLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33967-5104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-898-9131
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28811 S TAMIAMI TRL
Provider Second Line Business Practice Location Address:
SUITE #13
Provider Business Practice Location Address City Name:
BONITA SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34134-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-221-7123
Provider Business Practice Location Address Fax Number:
239-221-7987
Provider Enumeration Date:
06/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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