Healthcare Provider Details

I. General information

NPI: 1144863721
Provider Name (Legal Business Name): JEREMIAH BRADSHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 WESTMINSTER AVE APT 5
VENICE CA
90291-3660
US

IV. Provider business mailing address

48 WESTMINSTER AVE APT 5
VENICE CA
90291-3660
US

V. Phone/Fax

Practice location:
  • Phone: 323-627-7243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: