Basic Information
| Provider Information | |||||||||
| NPI: | 1134102544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAUST | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | PHYSICAL THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 860 SOUTHAMPTON RD | ||||||||
| Address2: | |||||||||
| City: | BENICIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077456144 | ||||||||
| FaxNumber: | 7077455698 | ||||||||
| Practice Location | |||||||||
| Address1: | 860 SOUTHAMPTON RD | ||||||||
| Address2: | |||||||||
| City: | BENICIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945101907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077456144 | ||||||||
| FaxNumber: | 7077455698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT28673 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ15795Z | 01 | CA | MEDICARE GROUP PTAN - VALLEJO | OTHER | ZZZ25256Z | 01 | CA | MEDICARE GROUP PTAN - BENICIA | OTHER |