Healthcare Provider Details

I. General information

NPI: 1467421834
Provider Name (Legal Business Name): JEREMY BRENT HAAS M.S., ATC/LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6480 W FLAMINGO RD SUITE B
LAS VEGAS NV
89103-7128
US

IV. Provider business mailing address

1000 AMERICAN PACIFIC DR APT 1124
HENDERSON NV
89074-8790
US

V. Phone/Fax

Practice location:
  • Phone: 702-251-9009
  • Fax: 702-251-9003
Mailing address:
  • Phone: 702-875-1256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0506101
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: