Healthcare Provider Details

I. General information

NPI: 1457113888
Provider Name (Legal Business Name): JEREMY CREASY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WOODLAKE DR
GOODVIEW VA
24095-2428
US

IV. Provider business mailing address

111 WOODLAKE DR
GOODVIEW VA
24095-2428
US

V. Phone/Fax

Practice location:
  • Phone: 540-330-3366
  • Fax:
Mailing address:
  • Phone: 540-330-3366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberT64335966
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: