MEDICARE: MR. JEREMY BRENT HAAS M.S., ATC/LAT, CSCS

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	2255A2300X	Athletic Trainer	0506101	NV

General Provider Information

NPI Number	:	1467421834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMY BRENT HAAS M.S., ATC/LAT, CSCS

Provider Business Mailing Address
First Line	:	1000 AMERICAN PACIFIC DR
Second Line	:	APT 1124
City	:	HENDERSON
State	:	NV
Zip	:	89074-8790
Country	:	US
Telephone Number	:	702-875-1256
Fax Number	:

Provider Business Practice Location Address
First Line	:	6480 W FLAMINGO RD
Second Line	:	SUITE B
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-7128
Country	:	US
Telephone Number	:	702-251-9009
Fax Number	:	702-251-9003

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

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	09/14/2009

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