Provider Demographics
NPI:1508039272
Name:BREACH, JEREMY M (LAC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:M
Last Name:BREACH
Suffix:
Gender:M
Credentials:LAC
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Mailing Address - Street 1:8230 E BROADWAY BLVD
Mailing Address - Street 2:SUITE E2
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-4044
Mailing Address - Country:US
Mailing Address - Phone:520-256-3733
Mailing Address - Fax:480-393-5740
Practice Address - Street 1:8230 E BROADWAY BLVD
Practice Address - Street 2:SUITE E2
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-4044
Practice Address - Country:US
Practice Address - Phone:520-256-3733
Practice Address - Fax:480-393-5740
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ0596171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist