Basic Information
| Provider Information | |||||||||
| NPI: | 1639898737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVERA VAZQUEZ | ||||||||
| FirstName: | JEREMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45211 HELM ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481706023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1734525971 | ||||||||
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| Address1: | 45211 HELM ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481706023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1734525971 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2022 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 242T00000X | Y | Technologists, Technicians & Other Technical Service Providers | Perfusionist |
No ID Information.