Healthcare Provider Details

I. General information

NPI: 1033363973
Provider Name (Legal Business Name): JEREMY DAVID LIVINGSTON CO, BOCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 11/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 LINDSAY LN
CODY WY
82414-4142
US

IV. Provider business mailing address

720 LINDSAY LN
CODY WY
82414-4142
US

V. Phone/Fax

Practice location:
  • Phone: 307-250-2443
  • Fax: 307-578-8820
Mailing address:
  • Phone: 307-250-2443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: