MEDICARE: JEREMIE DON FOWLER CRT

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	2278P1005X	Pulmonary Rehabilitation Certified Respiratory Therapist	335516-5701	UT

General Provider Information

NPI Number	:	1598969750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMIE DON FOWLER CRT

Provider Business Mailing Address
First Line	:	387 DIMAGGIO DR
Second Line	:
City	:	TOOELE
State	:	UT
Zip	:	84074-9297
Country	:	US
Telephone Number	:	435-882-4476
Fax Number	:

Provider Business Practice Location Address
First Line	:	4885 S 900 E
Second Line	:	SUITE 107
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5746
Country	:	US
Telephone Number	:	801-266-0399
Fax Number	:

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

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	07/08/2007

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