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General NPI Number Information
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NPI Number | 1427717040
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Entity Type | Individual
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Provider Name | JEREMY ROWAN THATCHER
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Gender | Male
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Dates
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Enumeration Date | 12/10/2021
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Last Update Date | 12/10/2021
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Provider Practice Location Address
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Address Line | 20 FAIRLAND DR
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City | NITRO
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State | WV
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Zip | 25143-1186
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Country | US
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Telephone | 304-552-2054
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Fax |
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Provider Business Mailing Address
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Address Line | 130 STONE ST
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City | CULLODEN
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State | WV
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Zip | 25510
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Country | US
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Telephone | 304-552-2054
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 126900000X
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Taxonomy Name | Dental Laboratory Technician
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License Number |
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License Number State |
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