Provider Demographics
NPI:1740759208
Name:MADRID, JEREMY JORGE JR
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JORGE
Last Name:MADRID
Suffix:JR
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 1:7465 DOVE CEEK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911
Mailing Address - Country:US
Mailing Address - Phone:719-694-6919
Mailing Address - Fax:
Practice Address - Street 1:7465 DOVE CEEK CIRCLE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911
Practice Address - Country:US
Practice Address - Phone:719-694-6919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer