=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578376448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMIAH FRANCOIS PHLEBOTOMY TECH 1
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2025
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1714 N MCCADDEN PL APT 1101
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90028-4678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-203-0584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1714 N MCCADDEN PL APT 1101
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90028-4678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-203-0584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | CPT-02454084
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------