Healthcare Provider Details

I. General information

NPI: 1922171792
Provider Name (Legal Business Name): JEREMY MICHEAL OWENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 ROUNDTREE DR
ELIZABETH CITY NC
27909-7711
US

IV. Provider business mailing address

508 ROUNDTREE DR
ELIZABETH CITY NC
27909-7711
US

V. Phone/Fax

Practice location:
  • Phone: 731-336-6367
  • Fax:
Mailing address:
  • Phone: 731-336-6367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: