Provider Demographics
NPI:1598181083
Name:CHILDS, JEREMY (LMT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:CHILDS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2148 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:WEST FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14170-9600
Mailing Address - Country:US
Mailing Address - Phone:716-364-5623
Mailing Address - Fax:
Practice Address - Street 1:3045 SOUTHWESTERN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1209
Practice Address - Country:US
Practice Address - Phone:716-364-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027783225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist