Healthcare Provider Details

I. General information

NPI: 1144080029
Provider Name (Legal Business Name): JEREMY THOMAS BOSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

5823 CROSS POINT CT
WAXHAW NC
28173-7103
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7249
  • Fax:
Mailing address:
  • Phone: 704-246-9602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: