Healthcare Provider Details

I. General information

NPI: 1346549367
Provider Name (Legal Business Name): JEREMY BRIAN DIENST CRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

IV. Provider business mailing address

5500 E. KELLOGG
WICHITA KS
67218-1607
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-2221
  • Fax:
Mailing address:
  • Phone: 316-685-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number16-02133
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: