Provider Demographics
NPI:1083046395
Name:BARD, JEREMY SCOTT (LPT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:SCOTT
Last Name:BARD
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2181 N BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-8223
Mailing Address - Country:US
Mailing Address - Phone:909-534-5823
Mailing Address - Fax:
Practice Address - Street 1:58945 BUSINESS CENTER DR
Practice Address - Street 2:SUITE D
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7307
Practice Address - Country:US
Practice Address - Phone:760-228-9657
Practice Address - Fax:760-369-6758
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36324167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician