Provider Demographics
NPI:1114472347
Name:MUMU, JEREMY J (DPT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:J
Last Name:MUMU
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6131
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:12402 INDUSTRIAL BLVD
Practice Address - Street 2:SUITE B2
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5871
Practice Address - Country:US
Practice Address - Phone:760-955-6061
Practice Address - Fax:760-955-6062
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA211312Medicare PIN