Healthcare Provider Details

I. General information

NPI: 1134665664
Provider Name (Legal Business Name): JEREMY BOWLIN PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2017
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S FREMONT AVE UNIT 27
ALHAMBRA CA
91803-8849
US

IV. Provider business mailing address

3737 MARTIN LUTHER KING JR BLVD STE 500
LYNWOOD CA
90262-3533
US

V. Phone/Fax

Practice location:
  • Phone: 626-289-7472
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number293010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: