Healthcare Provider Details

I. General information

NPI: 1326381534
Provider Name (Legal Business Name): JEREMY W COWIN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2693 E WASHINGTON BLVD
PASADENA CA
91107-1412
US

IV. Provider business mailing address

2750 HIGHVIEW AVE
ALTADENA CA
91001-5113
US

V. Phone/Fax

Practice location:
  • Phone: 626-593-2283
  • Fax:
Mailing address:
  • Phone: 818-795-9623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberAT3536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: