Healthcare Provider Details

I. General information

NPI: 1912364092
Provider Name (Legal Business Name): JEREMY TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25418 SUGAR VALLEY LN
SPRING TX
77373-8016
US

IV. Provider business mailing address

25418 SUGAR VALLEY LN
SPRING TX
77373-8016
US

V. Phone/Fax

Practice location:
  • Phone: 760-793-6275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: