Provider Demographics
NPI:1003085044
Name:VANCE, JEREMIAH T (CNIM)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:T
Last Name:VANCE
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 W 15TH ST STE 218
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5801
Mailing Address - Country:US
Mailing Address - Phone:972-985-9048
Mailing Address - Fax:972-596-7570
Practice Address - Street 1:4100 W 15TH ST STE 218
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5801
Practice Address - Country:US
Practice Address - Phone:972-985-9048
Practice Address - Fax:972-596-7570
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1449246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic