MEDICARE: MR. JEREMIE LEE KENT

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	172A00000X	Driver

General Provider Information

NPI Number	:	1760921951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMIE LEE KENT

Provider Business Mailing Address
First Line	:	1115 W MAIN ST
Second Line	:
City	:	LAKE CITY
State	:	IA
Zip	:	51449-1559
Country	:	US
Telephone Number	:	712-464-8074
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 W MAIN ST
Second Line	:
City	:	LAKE CITY
State	:	IA
Zip	:	51449
Country	:	US
Telephone Number	:	712-464-8074
Fax Number	:

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

Provider Enumeration Date	:	02/21/2017
Last Update Date	:	02/21/2017

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