Provider Demographics
NPI:1104380732
Name:THIO, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:THIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 MAGNOLIA AVE DEPT 1293
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1293
Mailing Address - Country:US
Mailing Address - Phone:951-222-8151
Mailing Address - Fax:
Practice Address - Street 1:4800 MAGNOLIA AVE DEPT 1293
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-1293
Practice Address - Country:US
Practice Address - Phone:951-222-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95043898163WC1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1400XNursing Service ProvidersRegistered NurseCollege Health