MEDICARE: DR. JEREMY FOX BUSTANOBY DPT

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	225100000X	Physical Therapist	2689	NV

General Provider Information

NPI Number	:	1962831214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY FOX BUSTANOBY DPT

Provider Business Mailing Address
First Line	:	3071 SAN MAMETE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89141-3542
Country	:	US
Telephone Number	:	757-406-9338
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 E HORIZON DR
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-8033
Country	:	US
Telephone Number	:	702-568-8450
Fax Number	:

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

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	11/07/2013

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