Healthcare Provider Details

I. General information

NPI: 1134389067
Provider Name (Legal Business Name): JEREMY M ENZ PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 RONALD REAGAN PKWY
AVON IN
46123-7085
US

IV. Provider business mailing address

1492 N COUNTY ROAD 425 E
AVON IN
46123-9587
US

V. Phone/Fax

Practice location:
  • Phone: 317-217-3070
  • Fax: 317-217-3073
Mailing address:
  • Phone: 317-859-0620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05006981A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: