Healthcare Provider Details

I. General information

NPI: 1831586973
Provider Name (Legal Business Name): JERRY LAW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 LARKSPUR LN APT 56
SACRAMENTO CA
95825-4186
US

IV. Provider business mailing address

2411 LARKSPUR LN APT 56
SACRAMENTO CA
95825-4186
US

V. Phone/Fax

Practice location:
  • Phone: 916-529-2876
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberA7315505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: