MEDICARE: JEREMY BURRESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZE0600X	Electroneurodiagnostic Specialist/Technologist

General Provider Information

NPI Number	:	1407202989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY BURRESS

Provider Business Mailing Address
First Line	:	2451 SEABRING DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-3156
Country	:	US
Telephone Number	:	928-846-6397
Fax Number	:

Provider Business Practice Location Address
First Line	:	2451 SEABRING DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-3156
Country	:	US
Telephone Number	:	928-846-6397
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2016
Last Update Date	:	05/13/2016

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