=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669968053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR JEREMY B BALL OD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2018
-----------------------------------------------------
Last Update Date | 07/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1659 E 6TH ST STE A
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-845-0272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35430 TRESA LN
-----------------------------------------------------
City | YUCAIPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92399-3232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-235-4345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. JEREMY BALL
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 951-235-4345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------