Healthcare Provider Details

I. General information

NPI: 1598056947
Provider Name (Legal Business Name): JEREMY DURST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 KEEWAYDIN DR
SALEM NH
03079
US

IV. Provider business mailing address

34650 CEDAR RDG
RICHMOND MI
48062-5571
US

V. Phone/Fax

Practice location:
  • Phone: 800-995-2673
  • Fax: 866-420-1055
Mailing address:
  • Phone: 810-434-1835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201007954
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: